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.

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