MedBank Application

Provider Name*

First NameLast Name
Facility Name
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone Number
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Office Fax Number
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Office Contact Name
Office Email
example@example.com
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose
Medication / Strength / Dose

In order to assist you quickly and efficiently, we ask that you take responsibility for the following:
• Proof of Income: In order to receive most medications, pharmaceutical manufacturers require patient to provide proof of income with the application. MedBank Case Specialists will work with you to ensure that you have the form required for your specific medications. This may include the following:
➢ 1040 Tax Form
➢ Schedule C Form (if self-employed)
➢ Four (4) consecutive and current pay stubs
➢ Proof of other income- family assistance, state assistance, Social Security Benefit letter, Social Security Disability Benefit, Pension, Alimony, Child Support, Unemployment, Etc.
➢ Unemployment- Wage Verification Form from the Department of Labor
➢ Medicaid Denial Letter
It is my responsibility as a patient of MedBank to keep medical provider information updated and current.

I understand that for MedBank to process my refills I must inform MedBank staff once I have received my medication, either at my home or at my doctor’s office. I understand that failure to do so may result in a delay in the arrival time of my next refill.

I understand that once my application is processed by MedBank staff, it will then be sent to the manufacturers according to their guidelines. I also understand that the estimated time of arrival for my medications can vary from 2 to 6 weeks after the application has received the necessary signatures from my doctor.

I understand that if I do not receive my medications within 6 weeks that it is my responsibility to notify the MedBank staff.

I understand that it is my responsibility to provide MedBank with the necessary proof of income to receive my medication, and that failure to do so may prevent me from receiving my medication.
Initial if you agree to the statements above.*

I authorize MedBank Foundation, Inc. and its affiliates to gather all medical records from my physicians, nurses, social workers, and any other personnel as needed. I understand that the information gathered will be used solely for the purposes of MedBank Foundation, Inc. and will not be released or shared with any outside institutions, companies, or other non- authorized personnel.
Further, I authorize MedBank Foundation, Inc. to release my medical information to pharmaceutical companies as deemed necessary for the purposes of processing applications and requests for prescription assistance.
This release shall only be valid from the date of signature to the end of my participation with MedBank Foundation, Inc. services or until I notify MedBank Foundation, Inc. in writing to discontinue services provided.
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