Transcription of INSTRUCTIONS - services.gileadhiv.com
{{id}} {{{paragraph}}}
Example: marketing
INSTRUCTIONS - services.gileadhiv.com
2017 Gilead Sciences, Inc. All rights reserved. ADMC0300 12/17 INSTRUCTIONSC omplete all applicable sections of the Enrollment Form. Section 1 (required): Check the box next to each support offering you are requesting from Advancing Access . Section 2 (required): Write the name and dosage of the Gilead product you are requesting assistance with fromAdvancing Access. Section 3 (required): Complete all fields with the patient s information. Section 4 (required): Check the appropriate box to indicate if the patient is insured or uninsured. If the patient is insured, fill in the patient s insurance information and fax a copy (front and back) of the patient s insurance card. If the patient has a secondary insurance, check the box to indicate this and fax a copy of the secondary insurance card. If the patient is uninsured, complete Section 9 to apply to the Patient Assistance Program/Medication Assistance Program (PAP/MAP).
health information privacy law(s), and any other applicable requirements, in order to release the patient’s personal and medical information to Gilead and its agents and contractors for
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
Your Accounts are Federally Insured, National Credit Union Administration, Your Insured Funds, Federally insured, CLINIC ELIGIBILITY GUIDELINES by FUNDING, CLINIC ELIGIBILITY GUIDELINES by FUNDING SOURCE IMMUNIZATION, Insured, Federally, Patient Eligibility Screening Record for Vaccines, Instructions for Completing the CMS