ENcourage Foundation® PATIENT ASSISTANT PROGRAM (PAP) PATIENT ENROLLMENT FORM INSTRUCTIONS Thank you for your interest in applying to the ENcourage Foundation®. The Foundation is a nonprofit organization that provides Enbrel® (etanercept) to qualifying patients at no cost. ELIGIBILITY GUIDELINES    Residence: You must reside in the United States, Guam, Puerto Rico or the U.S. Virgin Islands Insurance: You have no insurance for ENBREL and no access to other coverage or funding Income: Your annual household income meets program guidelines as follows: HOW TO APPLY CHECKLIST Patient: □ □ □ Complete the PATIENT INFORMATION section of the application If you have insurance, obtain your diagnosis code from your physician and enter it where noted Sign the PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION Provider: □ Complete and Sign the PRODUCT PRESCRIPTION FORM FAX OR MAIL THE COMPLETED APPLICATION Patient: Provider: Mail the completed application and the product Fax the completed application and the product prescription form to: prescription form to: ENcourage Foundation® OR 1 (888) 508 - 8083 PO Box 5730 Louisville, KY 40255-0730 Once a complete application is received and processed, both you and your provider will be notified of your eligibility. Missing information or an incomplete application will delay the enrollment decision. PO Box 5730 ● Louisville, KY 40255-0730 Effective February 2014 ● Phone: (800) 282-7752 Revision EF-001-A V3 ● Fax: (888) 508-8083 ● www.encouragefoundation.com Page 1 of 4 ENcourage Foundation® PATIENT INFORMATION (MUST COMPLETE ALL SECTIONS) MISSING INFORMATION OR AN INCOMPLETE APPLICATION WILL DELAY THE ENROLLMENT DECISION Patient Name: ________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ LAST Date of Birth: / Patient Mailing Address: / Social Security Number: ___________________________________________________________________________________________________________________________________________________________________________ STREET Telephone: ( ) _______________________________________ HOME MOBILE - - Sex: ________________________ __________________________________________________________________________________________ M.I. Male ____________________________________ CITY Female ____________________________________________________ STATE ZIP CODE ( ) ________________________________________ WORK Current Adjusted Gross Household Income: ____________________________________ FIRST HOME Weekly Bi-Weekly MOBILE Monthly Total Number of People Within Household (including yourself): Circle One 1 2 3 4 5 6 7 8 9 10 11 WORK $_____________.____ Yearly 12 13 14 15 _____ Must include anyone on your Federal Tax Return*. If you do not file a Federal tax Return include your spouse, children, and parents who live with you. * You do not need to file a tax return to apply for the ENcourage Foundation®. Have you lived in the United States or its territories for six months or longer? Yes No Have you lived in your current state for six months or longer? Yes No Are you a US citizen or resident alien? Yes No Are you pregnant? Yes No Are you blind or otherwise disabled? Yes No Are you a parent or caretaker relative of a child under the age of 18? Yes No Are you enrolled in Medicaid? Medicaid ID #_____________________ Yes No Have you been denied Medicaid? If yes, a M edicaid denial letter must be subm itted w ith this application Yes No Are you enrolled in Medicare? Yes No Yes No Are you eligible for other federal, state, or local government programs (VA/DOD/IHS)? Yes No Do you have commercial insurance? Yes No Emergency Only Medicare ID #_____________________ PHARMACY Insurance PHYSICIAN OTHER Insurance SECONDARY Insurance PRIMARY Are you enrolled in Medicare Part D? Pending If yes, the section below m ust be com pleted Insurer: Phone #: ( Subscriber Name: Relationship to Patient: Policy Number: Group Number: Insurer: Phone #: ( Subscriber Name: Relationship to Patient: Policy Number: Group Number: Insurer: Phone #: ( Subscriber Name: Relationship to Patient: Policy Number: Group Number: Insurer: Phone #: ( Subscriber Name: Relationship to Patient: Policy Number: ) - ) - ) - ) - Group Number: PHYSICIAN AND FACILITY INFORMATION Physician Name: _____________________ ______________________ LAST FIRST Preferred Contact Phone #: ( Preferred Contact Fax #: ( ) ) - Patient’s Diagnosis Code, i.e. ICD-9: R equired if patient has insurance _______________________________ PO Box 5730 ● Louisville, KY 40255-0730 Effective February 2014 ● Phone: (800) 282-7752 Revision EF-001-A V3 ● Fax: (888) 508-8083 ● www.encouragefoundation.com Page 2 of 4 ENcourage Foundation® PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION The ENcourage Foundation® (“the Foundation”) is a nonprofit patient assistance program supported by Amgen that provides qualifying patients with Enbrel® (etanercept) at no cost. Authorization to Disclose Information I authorize the Foundation, Amgen, their agents, and third-party contractors or their service providers authorized to administer the Foundation to: • use the information that I provided on the Foundation application form to determine my eligibility for and assist with my continued participation in the Foundation. • use my social security number to access my credit information and information derived from public and other sources to estimate my income in conjunction with the eligibility determination process. • contact me to seek feedback on the Foundation’s services. For these purposes, I also authorize my physician, healthcare professionals, health plan(s), care givers, and family members to disclose to the Foundation, Amgen, their agents, and third-party contractors or their service providers authorized to administer the Foundation information about my medical condition, treatment, and health insurance coverage. I understand that: • I may refuse to sign this form, but if I refuse to sign or revoke my authorization, I will not be able to receive assistance from the Foundation. • my healthcare provider or insurers will not condition my medical treatment or insurance benefits on my agreement to sign this form. • once I provide the information as described above to the Foundation, Amgen, the agents, and third-party contractors or their service providers working on their behalf pursuant to this authorization, federal privacy laws may not prevent further disclosure of this information. • I may receive a copy of this form at any time by contacting the Foundation at 1-800-282-7752, and I may revoke it by mailing a revocation to The Encourage Foundation, PO Box 5730, Louisville, KY 40255-0730. • a revocation must be in writing and is not effective to the extent that action has already been taken based on this authorization. • this authorization will expire one (1) year after the date it is signed below or one (1) year after the last date I receive product from the Foundation, whichever is later. Patient Certification I certify that: • the information I provided on the Foundation application form is complete and accurate. • I will not request reimbursement from any insurance carrier or government health benefit program for ENBREL that I receive from the Foundation. • I will notify the Foundation within thirty (30) days if my financial status or health insurance coverage changes. • If I decide to enroll in a Medicare Part D plan, I will inform the Foundation at the number below prior to enrolling. If I receive notice that I have “auto-enrolled” in a Medicare part D plan, I will immediately inform the Foundation. • I will not sell, trade, or distribute ENBREL given to me by the Foundation. I understand that completing the Foundation application form is not a guarantee of eligibility for the Foundation. I also understand that the Foundation may change or discontinue the program at any time without notice, except that if I am enrolled in a Medicare part D plan, my benefits will continue until the end of the calendar year. I understand that if I am currently enrolled in a Medicare Part D plan, I cannot utilize my Part D plan benefits for products received through the ENcourage Foundation® for the duration of my enrollment in the Foundation. Any medication I receive through the ENcourage Foundation® will not count toward my true-out-of-pocket (TrOOP) expenses in Medicare Part D. The ENcourage Foundation® will send a letter to my Medicare Part D plan notifying them of the assistance I am receiving for ENBREL. _______________________________________ _______________________________________ ______________ Signature of Patient or Personal Representative Name of Patient or Personal Representative Dated ________________________________________________________________________________________________ Description of Personal Representative’s Authority to Sign for Patient (Attach documents which show authority) PO Box 5730 ● Louisville, KY 40255-0730 Effective February 2014 ● Phone: (800) 282-7752 Revision EF-001-A V3 ● Fax: (888) 508-8083 ● www.encouragefoundation.com Page 3 of 4 ENcourage Foundation® PATIENT PRODUCT PRESCRIPTION FORM (MUST COMPLETE ALL SECTIONS) Patient Name (Required. Please print legibly): Gender: Male Female ________________________ ________________________ LAST FIRST . MEDICATION / DOSE Date of Birth: FREQUENCY / DISPENSE AMOUNT / REFILLS ® Enbrel (etanercept): Once weekly 12-wk supply 1-year Twice weekly for 3 months; then once weekly ____wk supply __month Once weekly 12-wk supply 1-year Twice weekly for 3 months; then once weekly ____wk supply __month 12-wk supply 1-year ____wk supply __month 12-wk supply 1-year ____wk supply __month 12-wk supply 1-year ____wk supply __month ® PRESCRIPTION (MUST BE COMPLETE) 50mg SureClick 50mg Prefilled Syringe Once weekly 25mg Vial Twice weekly Once weekly 25mg Prefilled Syringe Twice weekly ______________________ _____________________ FACILITY PRACTICE SHIPMENT INSTRUCTIONS: ENBREL is shipped to the patient directly. If you prefer to have the product shipped to the Provider’s office instead, please indicate here: Facility/Practice Name (Required): Ship to Provider’s Office Facility/Practice Contact Name (Required): PHYSICIAN Physician Name (Required. Please print legibly): _____________________________________ ___________________________________________ FIRST LAST . Phone #: ( ) - Fax #: ( ) - Street Address: ____________________________________ ______________________________ ______________ ___________ STREET (PO BOX NOT ACCEPTED) CITY STATE ZIP I have prescribed ENBREL for the above patient. My patient gave consent for me to provide this information. I understand that no third party or patient should be billed or charged for ENBREL provided by this program. I understand that no free product should be sold, traded, or distributed for sale. ____________________________________________________ __________________________ _______________ Physician’s Signature (stamps not accepted) State License # (Required) Date Completion of this form is independent of the application process and does not guarantee enrollment in the ENcourage Foundation®. The ENcourage Foundation® must review the complete application to determine the patient’s eligibility. PO Box 5730 ● Louisville, KY 40255-0730 Effective February 2014 ● Phone: (800) 282-7752 Revision EF-001-A V3 ● Fax: (888) 508-8083 ● www.encouragefoundation.com Page 4 of 4