Microsoft word - 2009 diabetes pap nml application- english.doc
Patient Assistance Program PO Box 181640 Louisville, KY 40261 Phone: 866-310-7549 Fax: 866-441-4190
PLEASE BE SURE TO COMPLETE BOTH PAGES OF THIS FORM. Incomplete applications will be returned. Submit the completed application with photocopies of the required proof of income to FAX 866-441-4190. Faxed requests must be sent from the healthcare practitioner’s office. Please allow up to 10 business days for processing.
Applications may also be mailed to the address above. Allow an additional 7 days for processing if mailed.
Approved patients will receive a 90-day supply of medication sent to the healthcare practitioner’s office. Subsequent requests
require a new application to be submitted. Income documentation is only required annually.
Both the patient and healthcare practitioner will be notified in writing of approved and denied requests.
Novo Nordisk reserves the right to modify or cancel this program at any time without notice. All requests are subject to product
availability and patient eligibility verification.
Please call Novo Nordisk toll-free at 1-866-310-7549 if you have questions.
Patient Information New Application / Annual Renewal 90 Day Re-order
_______________________________________________ Date of birth:____/____/_____
_______________________________________________ Gender: Male
__________________________________________________________________________
Patient’s phone number __________________________ Social Security number: _________________________
(required) Eligibility Requirements
A. Annual Household adjusted gross income from most recent federal tax return $ ___________________________ (Attach a copy of the patient’s most recent Federal Tax Return (1040), Social Security Income (SSA 1099), Pensions, Interest, Retirement, Child Support, etc. This information is only required annually. It is not required for 90-day reorders.) B. Number of dependents in household (including self) ____________________________________________________
C. Do you qualify for private, local, state or federal prescription insurance coverage? Yes
Please Attach Proof of Income Documents for all New Applications and Annual Renewals Incomplete Applications will be Returned
I reviewed the above Patient Assistance Program “the program” application completed by my physician and the information included on this
form is accurate and correct. I certify that payment for the requested medication represents a financial hardship to me, and that I do not have
access to third party reimbursement for the medication. I authorize my physician to disclose the information on this form to Novo Nordisk for
purposes of administering the program. I understand that once my physician discloses this information to Novo Nordisk, the information will
no longer be protected by federal privacy protection laws, but that Novo Nordisk will not further disclose the information included on this
form to anyone else, other than agents or vendors that may be employed by Novo Nordisk to assist Novo Nordisk in administering the program
or in sending me support literature and special offers. I understand that I have the right to receive a copy of this authorization from my
physician. My physician will not make any further disclosures of the information on this form to Novo Nordisk after one year from the date of
execution of this form. I understand that I can revoke this authorization at any time by writing to my physician and asking him or her not to
further disclose my information. I understand that my physician will treat me even if I do not sign this form, but that I will not be able to
Patient’s signature: _________________________________________________ Date: ____________________________
(No photocopies or power of attorney signature)
Yes, I would like to receive additional support literature and special offers from Novo Nordisk. I understand this will not affect my
eligibility for the Patient Assistance Program.
Patient’s signature: ____________________________________________ Email (optional): ______________________________________ Date: ____________________________
(No photocopies or power of attorney signature) Patient Information (Required for Valid Prescription)
_______________________________________________ Date of birth:____/____/_____
Healthcare Practitioner Information Practioner’s name:_________________________________________State License #:________________Exp Date:___________ Shipping Address: _______________________________________________________________________________________ (no P.O.Box number) _______________________________________________________________________________________ Phone number: _______________________________________ Fax number: ____________________________________ Email: _________________________________________________________________________
I agree that, in addition to communications regarding PAP, the information I have provided may be used for Novo Nordisk business
purposes, including but not limited to, providing me access to NovoMedLink ™resources and receiving facsimiles.
Prescription Information (Indicate Quantity Needed for 90 Day Supply)
Levemir® (insulin detemir [rDNA origin] injection) 368712 Levemir® 10 mL vials
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
NovoLog® (insulin aspart [rDNA origin] injection)
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
NovoLog® Mix 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin])
Max. dose per day _______ Sig_____________________________________
369619 NovoLog® Mix 70/30 FlexPen® (5x3 mL) **
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
231321 Novolin® R InnoLet® (5x3 mL) **
Max. dose per day _______ Sig_____________________________________
231421 Novolin® N InnoLet® (5x3 mL) **
Max. dose per day _______ Sig_____________________________________
231721 Novolin® 70/30 InnoLet® (5x3 mL) **.
Max. dose per day _______ Sig_____________________________________
NovoFine® 30G Disposable Needles (ONLY AVAILABLE FOR FlexPen® and InnoLet®)
185250 NovoFine® 30G Disposable Needles (100/box) Qty (boxes)_____ Use as Directed
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
PrandiMet® (repaglinide/metformin HCI tablets)
Max. dose per day _______ Sig_____________________________________
Max. dose per day _______ Sig_____________________________________
GlucaGen® HypoKit® (glucagon [rDNA origin] for injection)
Qty (kits)_____ Sig________________________________________________
** This item is used with NovoFine® disposable needles. Needles will NOT be sent if not requested. My signature certifies that goods received from Novo Nordisk are for the use of the above named patient only. These goods will not be resold
nor offered for sale, trade or barter and will not be returned for credit. I will not bill nor seek payment for the products from the patient or any
third party payor, including, but not limited to, Medicaid or private insurance plans. Novo Nordisk reserves the right to recall the product when
necessary. Practitioner’s signature: _______________________________________________________ Date: _______________________
FlexPen®, GlucaGen®, HypoKit®, Levemir®, Novolin®, NovoFine®, NovoLog®, and Prandin® are registered trademarks of Novo Nordisk A.S. 2009 Novo Nordisk Inc.
Physician Orders Adult Pneumonia, Community Acquired Admission Height:_________ Admission Weight:_________ Amission Status Admit to inpatient to Dr. _______________________service. IV Fluids Assign to observation status to Dr. ________________ service Dextrose 5% with 0.9% NaCl @ __________mL/hr Admit Location Dextrose 5% with 0.45% NaCl @ _________mL/hr □
LINCOLNSHIRE SAFEGUARDING ADULTS BOARD SERIOUS CASE REVIEW In respect of X (deceased) (Died 6 September 2006) EXECUTIVE SUMMARY 30 November 2009 INTRODUCTION X had Epilepsy and Autism Spectrum Disorder (ASD). His family home was in Nottingham, but his parents took the decision that he would be better cared for in specialist accommodation. Accordingly, during 1996 he be