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PAYMENT ASSISTANCE APPLICATION

Patient details

* Indicates required field

First Name : *

Last Name : *

Date of birth : *

Social security number : *

Phone number : *

Email address : *

Address *

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City

State

Zip Code

Country

Medical information - HIPAA Compliance

Medical Condition (Subject of application) *

Cost of the Treatment: *

Name of the Physician *

Phone Number of the Clinic *

Clinic Providing the treatment: *

Address of the the attending provider *

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City

State

Zip Code

Country

Financial information of patient

The amount of people living in the household of the patient: *

The annual income of the entire household: *

what is the maximum amount that you can afford for your treatment? *

Describe your financial situation *

Would you give the foundation for Regenerative Medicine permission to raise funds in your behalf using public announcement? *

Yes No

would you like to be an advocate for our organisation? *

Yes No

How did you hear about the foundation for Regenerative Medicine? *

In consideration for acceptance into the Foundation for Regenerative Medicine’s patient assistance program (Program), I agree and certify as follows:
• All information I have provided, and will provide, to the Foundation for regenerative medicine (Frm) in my request for assistance is and will be true and complete.
• I will promptly notify Frm of any changes to the information I have provided.
• I am free to change my physician, pharmacy, and medication at any time.
• Frm can, at any time, audit my program income eligibility and the accuracy of any documents or information I provide.
• If audited, I understand that if I do not promptly provide all income documentation and information requested by Frm, my grant will close. I may still submit the required documentation, however, Frm cannot guarantee funding will be available and payments will be made on a claim by claim basis. additionally, I will be required to submit income documentation each year before Frm will activate my pharmacy card (if applicable) or make any payments on my grant.
• If Frm determines I do not meet program eligibility or assistance requirements, my program participation and all assistance may be terminated.
• Frm may need to verify my diagnosis with my provider during my grant period and I will assist as needed in that process.
• I am not receiving financial assistance e for the same expenses for which I have applied, or will apply, to FRM.
• Neither Frm nor the organization administering the program, Covance market access services, is or will be in any way liable for the success or failure of any therapy or treatment I am taking.
• FRM and its agents can obtain and discuss medical, treatment, therapy, financial and other information relating to my Program assistance with my providers, pharmacy, employer, insurance company, and any other person or organization working on my behalf to obtain eligible treatment or therapy.
• Frm can, at any time and without notice, modify or discontinue all or any part of the program and/or any assistance provided to me.
• I will carefully review all of the terms and conditions on the back of my approval letter before seeking any program assistance, whether by reimbursement request or usage of a Frm pharmacy card.
• I will fully comply with such terms and conditions and all program eligibility and other requirements and if I fail to do so, my program participation and all assistance can be terminated.

BY CLICKING THE SUBMIT BUTTON, I AM ATTESTING THAT I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE PATIENT ATTESTATION OUTLINED ABOVE.

I agree to receiving marketing and promotional materials

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PAYMENT ASSISTANCE APPLICATION

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