Xifaxan Patient Assistance Enrollment

Bausch Health Patient Assistance Program (PAP) Enrollment Questionnaire
The following form is used to complete the Bausch Health Patient Assistance Enrollment Application. Spencer's Pharmacy is a Specialty Pharmacy that works with your doctors office to assist in collecting and completing the application.

Before you begin - please make sure you have the following availible (you will need it to complete the questionnaire):
- Personal Identification (Drivers License, Passport or Social Security Card)
- Medicare Insurance Card / Prescription Insurance Card
- Household Income / Tax Information (optional)
*Social Security Number (SSN) is required to complete the application - Failure to provide the SSN will place the application on a HOLD Status*
Personal Information

Please provide your personal information in the section below
Full Name*

First NameLast Name
Address*

Street Address

Unit / Apt #

CityState

Zip Code
Please provide a copy of your identification

Acceptable documents include: Drivers License, Passport or Social Security Card
Personal Identification Upload *

Please take a photo or upload your document
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Date of Birth (mm/dd/yy)*

MonthDayYear
Gender*

MaleFemale
Phone Number*
Please enter a valid phone number.
Phone Type*

Home PhoneMobile Phone
Email*
example@example.com
Do you have any medication allergies?*
Social Security #*
SSN is required for enrollment and verification.
Alien ID # (IF APPLICABLE)
Please provide the Alien ID # if applicable
Insurance Information

Please provide information regarding your Medical/Prescription Insurance Information.
Select you Part D Plan*
Please select your plan
Other Plan:
FRONT of the Card *

Please take a photo of the front of the card
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BACK of the Card*

Please take a photo of the front of the card
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Personal Finance Information

Please provide information regarding your most recent Personal Finances.
What is your ANNUAL Household Income *
Please estimate annual household income
Check Number of People in Household (Include Self)*

123456+
See below if you do not have any income to declare.

CHECK THIS BOX IF YOU HAVE NO INCOME.
Financial Documentation

Please be advised that Bausch Health may request financial documentation to support the application.

If you do not have this documentation or prefer not to share this information - you do not have to provide the information at this time.
Please select the financial document you would like to provide

W-210994506TSocial Security statement/checks/benefit letterPension or disability benefit statement/letterUnemployment compensation statementPay stubOther
Finance Document(s) Upload

Please take a photo or upload your finance document. You may upload MULTIPLE documents.
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HIPAA ACKNOWLEDGEMENT/CONSENT
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you (pharmacy) to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
- Obtaining payment from third party payers (e.g. my insurance company);
- The day-to-day healthcare operations of your practice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Pratices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
I have read the statement above and attest that the information submitted is correct.*

Clear
Date

MonthDayYear
Date
Should be Empty:

Bausch Health Patient Assistance Program (PAP) Enrollment Questionnaire

Personal Information

Please provide a copy of your identification

Insurance Information

Personal Finance Information

HIPAA ACKNOWLEDGEMENT/CONSENT