Pharmacy Form Draft

Total number of people in household:
Total monthly gross household income (all members)
Is household income equal to or below the limit for household size?
Do you have all necessary documentation (ID, proof of income, proof of residency)?
Do you have:
Do you have Medicare Part D (ask to see Medicare card)?
Do you have a primary care physician?

Name
First Last
Clinic
Phone
Fax Number
*
I agree*
I acknowledge that the information concerning income has been explained to me and that I understand it. I also understand that I
'have been certified for the time period listed above. I understand that all new and refill prescriptions may be dispensed in non-child resistant containers.

Permission for Patient Assistance Program Review of Patient Records:
I attest to the above information as true to the best of my knowledge and will report any changes of my insurance status or income to St. Vincent de Paul immediately. I hereby authorize St. Vincent de Paul to share any of my information, including
prescription records, with any Patient Assistance Program(s) for which I qualify, or the Program designee(s), in order to
coordinate services, and/or for internal auditing purposes.

I understand that I may revoke this consent at anytime by contacting St. Vincent de Paul except when action has already been taken to obtain and/or release such information. My signature on this release indicates that I have read the above, or have had it read to me, and that I understand the terms and conditions. I have also had the opportunity to ask any questions. If applicable, I am also signing this release on behalf ofmy children that are under the age of eighteen (18). I understand that ifl wish to revoke this consent, I must do so in writing.

In order to access Bulk Replacement Programs each patient must be the signer of their own application.
Name of Client
First Last
Date
Date Format: MM slash DD slash YYYY
Name of Parent or Guardian (if client is under 18)
First Last
Date
Date Format: MM slash DD slash YYYY
Name of Staff Member
First Last
Date
Date Format: MM slash DD slash YYYY
Recertification Date
Date Format: MM slash DD slash YYYY

Prescription Assistance Eligibility Form
Name
First Middle Last
Gender
Age
Date of Birth
MM
DD
YYYY
Marital Status
Home Phone
Cell Phone
Address*
Street Address Address Line 2 City ZIP Code
County*
Mailing Address (If Different)
Street Address Address Line 2 City ZIP Code
County
Ethnicity (Select All that Apply)
Family Household Information ( Select All that Apply)
Number of People in household 18 and over
Number of Children under 14
Number of Children over 14
*
I agree
IT IS YOUR RESPONSIBILTY TO PROVIDE:
CURRENT PROOF OF INCOME AND RESIDENCY. IF YOU DO NOT PRODUCE SUCH DOCUMENTS YOU WILL NOT BE ELIGIBLE FOR SERVICES. I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Signature*
Date
Date Format: MM slash DD slash YYYY
Signature of Staff Member*
Date
Date Format: MM slash DD slash YYYY

Today's Date
Date Format: MM slash DD slash YYYY
Client Name*
First Last
Client Email
Date of Birth
MM
DD
YYYY

Please list all prescriptions that the patient needs below:
Encounter(N/T/R/E)
Encounter Type Key: N=New T=Transfer R=Refill E=Education
Drug Name & Strength
Prescription#
Pharmacy Name
Pharmacy Phone
Encounter(N/T/R/E)
Encounter Type Key: N=New T=Transfer R=Refill E=Education
Drug Name & Strength
Prescription#
Pharmacy Name
Pharmacy Phone
Encounter(N/T/R/E)
Encounter Type Key: N=New T=Transfer R=Refill E=Education
Drug Name & Strength
Prescription#
Pharmacy Name
Pharmacy Phone
Encounter(N/T/R/E)
Encounter Type Key: N=New T=Transfer R=Refill E=Education
Drug Name & Strength
Prescription#
Pharmacy Name
Pharmacy Phone
Encounter(N/T/R/E)
Encounter Type Key: N=New T = Transfer R=Refill E=Education
Drug Name & Strength
Prescription#
Pharmacy Name
Pharmacy Phone
Please list all Allergies:
Comments/Referral:

Pharmacy Eligibility Application

Step 1 of 6

DOCUMENTS NEEDED FOR CERTIFICATION (2020)

Prescription Assistance Eligibility Form

Please list all prescriptions that the patient needs below: