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PRESCRIPTION ASSISTANCE

Please start by telling us about yourself.

Please enter your First Name Please enter your Last Name Please enter your Member Number Please enter your Birth Date Please enter the Effective Date of your Membership Please enter your Primary Phone Number Please enter your Cell Phone Number

Our assistance programs can be based on qualification, please make sure to provide the most accurate and up-to-date information.

Yes No Please tell us if you are married
Please tell us how many dependents you have
Please enter your Monthly Income
Wages
SSI
Disability
Unemployment
Pension
Other
Please provide us with
your income information

Please enter your Monthly Income
Wages
SSI
Disability
Unemployment
Pension
Other
Please provide us with your
spouse's income information

Please provide the information for your current Doctor who is prescribing your medications.

Doctor First Name Doctor Last Name Address City State
Zip Code Phone Number Fax Number

    Your Doctors

    1.                 Edit Doctor
      Doctor First Name Doctor Last Name Address City State
      Zip Code Phone Number Fax Number

    * Please note: it is important to make sure you assign each medication to the doctor that is prescribing it, make sure to enter ALL doctors you are seeing during this step.

    We need your doctors information to continue.

    Please add your medications.

    Medication Name
    ie. Metformin
    Medication Directions
    ie. twice a day
    Dosage
    ie. 750mg
    Quantity
    ie. 60
    Cost
    ie. $100
    Prescribing Doctor

    * Please note: make sure to fill out the correct spelling, directions, dosage and quantity needed for a one month supply

      Your Medications

      1.            

      We need your doctors information to continue.

      Applicant Authorization for Use and Disclosure of Personal Health Information

      I understand and agree by submitting this information I am authorizing the HCCUA to identify and help me apply for various pharmaceutical manufacturer patient assistance programs for which I may qualify, in order to reduce or eliminate the cost of medications. I also understand that many of these programs are income based and are subject to qualification guidelines. I understand that in order for the HCCUA to provide me with assistance, it will need to obtain, review, use and disclose my personal health information (PHI), including information relating to my medical condition and information on my application form. I authorize my physician, pharmacy, and my health plan(s) to disclose my PHI to the HCCUA and its administrators as necessary to complete the Prescription assistance process or to verify my application. I understand that my name, address, and any other personal identifying information provided in my application will be available to HCCUA and its affiliates. I understand that my PHI disclosed under this application may no longer be protected by privacy laws and may be re-disclosed by the HCCUA only for the purposes described here. I understand that if I don't provide this Authorization, I won't be able to obtain assistance. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician and the HCCUA and the cancellation will not apply to any information already used or disclosed pursuant to this Authorization. If I do not cancel this Authorization, the Authorization will expire 15 months from the date submitted below. I have read this document or have had it explained to me. I understand that I may request a copy of this Authorization once it has been submitted.