First Name
Last Name
Date of Birth
Member Number
Effective Date
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
Doctor's Name
Doctor's Specialty
Office Phone
Office Fax
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
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
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.
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