Application for Scipher's Patient Assistance Program
Personal Information
Please fill out this section completely.
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
General Financial Information
Fill out the corresponding sections that best describes your situation.
Patient's annual gross household/family income?
*
Number of Household Members?
*
Complete all required fields, and submit: Copy of individual tax return (1040) for current tax year and a copy of two most recent pay stubs
*
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Cancel
of
I understand if Scipher is not able to to pre-qualify my application, I will be mailed a hard copy application and will be required to provide additional documentation to support my financial assistance application
*
Yes
No
Application Authorization
I authorize Scipher to use and/or disclose among Scipher the information on this application to assess my eligibility for participation in the financial assistance portion of the PAP program, including the audit of my medical records and/or by contacting me directly to confirm my eligibility and matters related to such program. I understand that this assistance is temporary, and that the PAP may be discontinued or change at any time. I authorize my physician to disclose individually identifiable health and medical information to Scipher solely for the purposes of my participation in the PAP. I understand that if I refuse to sign this authorization, I will not be able to participate in the financial assistance portion of PAP, but it will not affect my ability to obtain medical treatment, my ability to seek payment for treatment or affect my future insurance enrollment or eligibility for insurance benefits. I understand that I may cancel this authorization at any time by mailing a letter to Scipher (Scipher Medicine, PO Box 412849, Boston, MA 02241). Cancelling this authorization will prohibit disclosures of my personal information after the date the cancellation letter is received and processed but will not affect disclosures made before that time. This authorization expires at the end of participation in PAP or if Scipher does not approve my application for participation in the financial assistance portion of the PAP program.
Signature
I certify that I have read the Authorization Statement in full and that I understand and agree to the terms stated therein by signing below.
Patient Name
*
First Name
Last Name
Patient Signature (or personal representative)
*
Name of personal representative (if applicable)
Personal representative's relationship to patient
Date
*
-
Month
-
Day
Year
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Please verify that you are human
*
Submit
Submit
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