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Patient Application
APTALIS PATIENT ASSISTANCE PROGRAM
1 Patient Information: Please complete all required information
Patient First Name ______________________________Last Name ____________________________________ Patient Address _____________________________________________________________________________ City ____________________________________State _______Zip__________Phone______________________ Date of Birth____/____/____ Sex ■ Male ■ Female Number of persons (including self) DEPENDENT upon the family income________ US Citizen or permanent US Resident ■ Yes ■ No Social Security Number _________________________________ Do you currently have prescription drug coverage such as: Other state or local drug coverage ■ YES ■ No TOTAL GROSS MONTHLY HOUSEHOLD INCOME: Proof of income from all sources must be attached (see reverse side for details).
Total Monthly Income
I attest that the information provided in this application is complete and accurate. I understand that all personal identifying information obtained by Aptalis in response to this application willbe used by Aptalis and its authorized agent(s) to administer the Program and will not be used or disclosed for any other purposes, except as may be required or permitted by applicable law.
I also understand that information about all program participants may be summarized for statistical or other purposes, but that my identity cannot be determined from this summaryinformation. I understand that Aptalis reserves the right at any time and without notice to modify the application form or the eligibility criteria, modify or discontinue any or all aspects of theProgram or terminate any assistance provided by the Program. I understand that my prescribing physician is responsible for choosing which prescription products are right for me. AptalisPharma U.S. Inc., is not responsible for verifying my medical condition or my prescribing physician’s selection of products.
Patient’s Signature ____________________________________________________Date _________________
2 Physician Information: Please complete all required information
Prescriber First Name _____________________________Last Name __________________________Title ________Prescriber Address ___________________________________________________________________________City _____________________________________________________State _______Zip __________________Phone________________________________________Fax # ________________________________________To the best of your knowledge does the patient have prescription drug coverage ■ Yes ■ No Please check the product(s) requested for this patient: ■ Zenpep®
■ Pylera®
■ Ultresa™
■ Canasa®
■ Rectiv®
■ Viokace™
I certify that the information provided in this application is complete and accurate to the best of my knowledge and that the product requested hereunder is medically indicated for this patient.
I understand that eligibility under this Program is subject to Aptalis’ approval and the patient’s continuing compliance with all eligibility requirements, as set by Aptalis from time to time. I certify that a patient signed HIPAA form is on file.
Prescriber’s Signature __________________________________________________Date _________________
(photocopies or stamped signatures will not be accepted)
State License # (Required)_________________________________________ Professional Designation (Required) _________________
See program information on reverse side.
3 Eligibility Criteria:
Patients must meet all of the following guidelines to qualify for the Aptalis Patient Assistance Program: • Be a US Citizen or permanent US Resident.
• Have no prescription drug benefits through any insurer/payer/program including Medicare, VA, other state/local program or private insurer.
• Have gross annual household income at or below: 48 CONTIGUOUS
FAMILY UNIT
STATES, DC
• Proof of income will be required. Examples are outlined below.
4 Proof of Income:
Proof of monthly income for all persons in the household must be attached. Acceptable documents include:
(a) Recent pay stub (current within the last two months)
(b) Tax Form 1040/1040 EZ or most recent W-2 or 1099 Form (c) Monthly benefits (Social Security, etc.) which can be award letter, benefit statement, or bank
statements showing automatic deposit for the current calendar year (d) Self-employed patients must attach a copy of most current Federal Income Tax form with appropriate (e) If you have no income, you must attach a note from your physician, or social worker on their letterhead stating to the best of their knowledge you have no income.
5 RETURN Completed Application with proof of income to:
Aptalis Patient Assistance ProgramP.O. Box 2240Morrisville, PA 19067-0540 If you have questions, please call the Aptalis Patient Assistance Program at 1-866-514-2442. A customer servicerepresentative is available between the hours of 8:30 a.m. and 5:30 p.m. ET Monday through Friday, excluding holidays.

Source: http://www.aptalispap.com/pdf/application-form.pdf