Patient Enrollment Application

Patient Enrollment Application
Please review enrollment information below. Complete form by clicking each section to expand and fill in missing information.

Patient Infomation
Date

MonthDayYear
Date
ID or SSN
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Alternative Contact
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Work Extension
Email Address
example@example.com

Income Information
Annual Household Income
Number of people in household

Physician Information
Physician Name
Physician Phone Number
Please enter a valid phone number.
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician NPI

Diagnosis Information
Diagnosis
Medication
Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.

Major Medical Insurance Information
Insurance Name
ID#
Group#
Phone
Please enter a valid phone number.

Drug Card Information
Insurance Name
ID#
BIN
PCN
Insurance Phone Number
Please enter a valid phone number.
Is this a Medicare, Federal or State funded insurance plan?

YesNo

Documentation
Insurance Card (front and back) & Income Documentation

Cancelof

Declaration, Liability & Patient Attestation
You attest and certify to Immune Recovery Foundation and its agents that the information provided in your application is complete and accurate. You understand that, and consent to, your reported financial information being verified by an audit as deemed necessary by Immune Recovery Foundation. Immune Recovery Foundation, and its authorized third-party agents, such as credit monitoring companies, may use your demographic information, including but not limited to your social security number, date of birth, name, and address in order to estimate your income in conjunction with the eligibility process. You understand that Immune Recovery Foundation, and its authorized third-party agents, reserve the right to ask for additional documents and information at any time. As a soft credit inquiry, this does not impact your credit score.

You further understand that any false or incomplete information provided by you to Immune Recovery Foundation could unduly harm your application process, Immune Recovery Foundation, its reputation, and its tax status. You also understand that if Immune Recovery Foundation becomes aware of any inaccurate information or fraudulent activity relating to your application, all services may cease. You understand that you are free at any time to switch providers, practitioners, suppliers, or treatments for your diagnosis without affecting your continued eligibility for Immune Recovery Foundation’s assistance.

You understand that you are not guaranteed or promised assistance. Any services or assistance Immune Recovery Foundation may provide is limited to the terms and conditions established by Immune Recovery Foundation. Immune Recovery Foundation reserves the right at any time, and for any reason without notice, to modify the eligibility criteria or modify or discontinue any support services assistance.

Limitation of Liability:
You agree that Immune Recovery Foundation, our sponsors, and our donors shall not be liable for any damages of any kind, without limitation, arising out of or in connection with you receiving navigation support, financial assistance, co-pay relief, or other value-added benefits or services provided as a part of this program.

Patient Attestation:
You agree to be fully compliant in taking the drug for which financial assistance is being provided in accordance with your doctor’s directions.
By checking the box below you agree that you have read, understand and agree to adhere to the above statements*

I AGREE

Terms and Conditions
n order for you to receive services and support assistance through Immune Recovery Foundation, you authorize your physicians, pharmacies and insurance companies to disclose to Immune Recovery Foundation and its applicable contractors, employees, agents and other representatives your personal information. In addition you authorize Immune Recovery Foundation to use and disclose your personal information to Immune Recovery Foundation’s agents, third parties acting on its behalf, credit monitoring companies, or any of your healthcare providers.

Your personal information may include, but not be limited to, your name, address, phone number, email address, date of birth, social security number, insurance status and numbers, amount of any financial assistance allocated and dispensed, diagnosis information, and treatment information.

You consent to the disclosure of your personal information for the following purposes: (i) to enable Immune Recovery Foundation to determine whether you are eligible and qualify for support services assistance. (iii) to refer you to, or to determine your eligibility for, other programs, foundations or sources of funding or coverage for your healthcare costs, products and services; (iv) to facilitate the audit or review of Immune Recovery Foundation’ operations; and (v) to enable Immune Recovery Foundation to manage its patient support services assistance programs.

You understand that your personal information that is disclosed may be re-disclosed by the recipient and no longer protected by federal or state privacy regulations and laws. You consent to Immune Recovery Foundation re-validating your personal information. You consent to Immune Recovery Foundation electronically disclosing your personal information to third parties as permitted or required by law.

You may revoke this consent at any time by mailing a signed letter of revocation to Immune Recovery Foundation’ Privacy Officer at 10015 Old Columbia Road, Suite B215 Columbia, MD 21046 or faxing the written consent to Immune Recovery Foundation’ Privacy Officer at the following fax number: (800) 821-1230. Revoking this consent will not have any effect on actions that Immune Recovery Foundation took in reliance on the consent before it received notice of your revocation. If you revoke this consent, you will not be able to receive future support services assistance through Immune Recovery Foundation. However, your applicable healthcare providers and insurance companies, who are disclosing the information to Immune Recovery Foundation, may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this consent.

This consent expires six years from the date that you last receive assistance from Immune Recovery Foundation, if not revoked sooner.
By checking the box below you agree that you have read, understand and agree to adhere to the Terms and Conditions above*

I AGREE
Signature*

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