First Name

Last Name

Date of Birth

Member Number

Effective Date

Address

Address

City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

Email

How Many People Live in the Household?

Member Monthly Household Income

Type of IncomeWagesSSIDisabilityUnemploymentPensionOther

Spouse Monthly Household Income

Type of IncomeWagesSSIDisabilityUnemploymentPensionOther

Doctor's Name

Doctor's Specialty

Office Phone

Office Fax

Address

Address

City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Do You See Additional Doctors?YesNo

If so, Please Provide the Following Information About Each Additional Doctor You See (Doctor's Name, Specialty, City, State, Zip Code, Office Phone, Office Fax).

Allergies

Conditions

Supplies

Medication Name

How Often is this Medication Taken?

Prescription Quantity

Prescription Dosage

Prescription Cost

Medication Name

How Often is this Medication Taken?

Prescription Quantity

Prescription Dosage

Prescription Cost

Medication Name

How Often is this Medication Taken?

Prescription Quantity

Prescription Dosage

Prescription Cost

Do You Take Additional Medications?NoYes

If so, please list the additional medications (Medication Name, How Often You Take this Medication, Dosage, Prescription Quantity, Prescription Cost).

Applicant Authorization for Use and Disclosure of Personal Health Information (PHI)

I understand and agree that by submitting this information that I am authorizing iCan to identify and help me to 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 iCan to provide me with assistance, iCan administrators and affiliates 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 iCan administrators and affiliates 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 iCan administrators and affiliates. I understand that my PHI disclosed under this application may no longer be protected by privacy laws and may be re-disclosed by iCan only for the purposes described here.

I understand that if I decline this authorization that I will not be able to obtain assistance through this application. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician and iCan; however, 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.

I have read these terms for Authorization and understand what is being described. I understand that I may request a copy of this Authorization once it has been submitted.

I Agree to this Authorization