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The Novartis Patient Assistance Foundation (NPAF) provides a critical resource for patients who struggle to afford prescribed medications. The Patient Assistance form is designed to gather essential information from individuals seeking support. To qualify, applicants must be U.S. residents, meet specific income criteria, and have limited or no prescription coverage. The form is divided into several sections, each requiring meticulous attention to detail. Patients must complete their personal information, verify any existing insurance coverage, and provide proof of income. An electronic income verification option is available to expedite processing, but patients also have the option to submit traditional financial documents. Additionally, they can opt-in for automated reminders regarding medication refills, enhancing management of their treatment. A significant component of the application is the Patient Authorization, which permits the sharing of personal information with healthcare providers and insurers to facilitate enrollment. It is also essential for applicants to collaborate with their healthcare provider to ensure all necessary documentation is completed accurately. The application can be submitted either via fax or mail to ensure efficient handling of requests. This comprehensive approach reinforces the NPAF’s commitment to helping patients receive necessary medications, thereby improving their quality of life.
Novartis Patient Assistance Example
www.PAP.Novartis.com
Phone:
Novartis Patient Assistance Foundation, Inc.
Thank you for your interest in the Novartis Patient Assistance Foundation, Inc. (NPAF)
Please visit www.PAP.Novartis.com for a complete list of medications and income requirements.
Eligibility Criteria – To be eligible, a patient must:
•Be a U.S. resident
•Meet the income requirements
•Have limited or no prescription coverage
Instructions
To see if you are eligible, you will need to complete Patient Sections
•Patient Section 1: Fill out your information completely and accurately. This will allow us to review your case and determine your eligibility for our program.
•Patient Section 2: If you have insurance, you will need to include a copy, of both the front and back, of all insurance cards (covering medical and prescription). This will allow us to verify your benefit coverage.
•Patient Section 3: You will need to provide proof of your household’s gross income. You can choose ONE of the following options to verify your proof of income:
OR
Most recent year’s tax return |
Three months of paycheck stubs |
W2 form |
Social Security statement (1099) |
•Patient Section 4: If you become enrolled, we can use our autodialer/automated system to remind you when your next refill order can be placed and we can text you eligibility and refill information. For this option, please read and check the Telephone Consumer Protection Act (TCPA) Consent if you want to allow us to contact you this way. This is optional and may be easier to help you manage your enrollment.
•Patient Section 5: We need you to read the Patient Authorization page to allow us to process your application, communicate with you and manage your enrollment. Please read, sign and date at the bottom of the Patient Application.
Lastly, work with your health care provider (HCP) to complete his/her sections of the application. If you have insurance and your policy requires a Prior Authorization, your HCP will need to obtain it and include it with their portion of the application.
Fax or mail your completed application to:
Fax:
PLEASE KEEP THIS PAGE FOR YOUR RECORDS.
www.PAP.Novartis.com Phone:
Novartis Patient Assistance Foundation, Inc.
Patient Authorization
I give permission for my health care providers (HCPs), pharmacies, service providers and their contractors (“Health Care Providers”), health insurer(s) and their contractors (“Insurers”), to disclose my personal information, including information about my insurance, prescriptions, medical condition, and health (“Personal Information”) to the Novartis Patient Assistance Foundation, Inc. (“NPAF”) so that NPAF can administer the NPAF program by: (i) providing me with access to the product which I am prescribed, (ii) helping to verify insurance coverage, (iii) providing me with information about Novartis products, (iv) providing me with medication reminders, and (v) conducting quality assurance, surveys, and/or other internal business activities in connection with the NPAF program.
I give permission to NPAF to disclose my Personal Information to my Health Care Providers, Insurer(s), caregivers, Novartis Pharmaceuticals Corporation, its affiliates, service providers, and agents (“Novartis”), for the purposes described above. I also give permission to NPAF to combine or aggregate any information collected from me with information NPAF may collect about me from other sources for the purpose of providing or administering program services.
I understand that once my Personal |
Information is disclosed it may no longer be protected |
by federal privacy law and applicable |
state law. I understand that I may refuse to sign this |
authorization. I also may revoke (withdraw) this authorization with respect to NPAF at any time in the future by calling
My refusal or future revocation will not affect the commencement or continuation of my treatment by my HCPs; however, if I revoke this authorization, I may no longer be able to participate in programs administered by NPAF. If I revoke this authorization, NPAF will stop using or sharing my information (except as necessary to end my participation in NPAF) but my revocation will not affect uses and disclosures of Personal Information previously disclosed in reliance upon this authorization. I understand that this authorization will remain valid for five (5) years after the date of my signature, unless I revoke it earlier. I also understand that programs administered by NPAF may change or end at any time without prior notification. I understand that I may receive a copy of this authorization.
I agree to be contacted by NPAF by mail,
telephone |
number(s) provided and |
the |
authorized user |
for |
the |
|
I |
agree to |
notify NPAF promptly |
if any |
of my numbers |
or |
addresses change in the future. |
I |
understand that my wireless service provider’s message and data rates may apply. |
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I understand that the Companies do not permit my Personal Information to be used by their business partners for their own separate marketing purposes. I understand and agree that Personal Information transmitted by
PLEASE KEEP THIS PAGE FOR YOUR RECORDS.
www.PAP.Novartis.com Phone:
Novartis Patient Assistance Foundation, Inc.
Patient Application
SECTION 1: Patient Information |
|
|
Please check one of the following: I am |
I am a new patient |
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Patient’s Name: __________________________ Date of Birth: _______/_______/_______ |
||
Gender: M F |
U.S. Resident: Y N |
Veteran: Y N Disabled: Y N |
Address: __________________________________________________________________________ Apt/Unit #: _________________
City: _____________________________________________ State: ___________________________ Zip Code: __________________
Cell #: _______________________ Home #:_______________________ Email:_____________________________________________
Annual Gross Income: $_________________ Total number of people in your household (including self): _____________
Caregiver/Family Member Name: _________________________________ Relationship: _______________________
By providing this information, you authorize NPAF to discuss your health condition and participation in the NPAF program with the person named above.
SECTION 2: Insurance Information |
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Do you have Medicare? Y N If YES, check all that apply |
Part B Part D |
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Do you have coverage through a state Medicaid Program? |
Y |
N |
Do you have prescription drug or medical insurance? Y |
N |
|
Primary Insurance Company Name: __________________________________ Phone #: ________________________________
ID #: _________________________________ GROUP #_____________________ BIN # ____________________________________
Secondary Insurance Company Name: _______________________________ Phone #: ________________________________
ID #: _________________________________ GROUP #_____________________ BIN # ____________________________________
SECTION 3: Fair Credit Reporting Act (FCRA) Consent
As described on the Instructions Page, you have the option to allow NPAF to perform an electronic income verification to process your application. Please check here if you wish to choose this option and not send in your income documents as noted on the Instructions Page.
I understand that I am providing “written instructions” under the FCRA, authorizing NPAF and its vendor, on an ongoing basis as needed for the duration of my participation in programs administered by NPAF, to obtain information from my credit profile or other information from the vendor, solely for the purpose of determining financial qualifications for programs administered by NPAF. I understand that I must affirmatively agree to these terms in order to proceed in this financial screening process.
SECTION 4: Telephone Consumer Protection Act (TCPA) Consent
As described on the Instructions Page, you may allow us to contact you using an automated dialing system,
I consent to receive marketing calls and texts from and on behalf of NPAF, made with an auto dialer or prerecorded voice, at the phone number(s) provided. I understand that my consent is not required or a condition of purchase. Number of messages will vary based on your program selections. Message and data rates may apply.
SECTION 5: Patient Authorization
I confirm my information above is correct and that I have read and agree to the Patient Authorization.
PATIENT SIGNATURE:_______________________________________________ |
DATE: ______/______/________ |
(REQUIRED) |
(REQUIRED) |
www.PAP.Novartis.com Phone:
Novartis Patient Assistance Foundation, Inc.
Prescriber Application
SECTION 1: Prescriber Information
Prescriber Full Name: _________________________________________ Phone Number: _____________________ Fax: ____________________
Facility Name or Group Practice Name, if applicable: ___________________________________________________________________________
Office Coordinator Name: _____________________________________ Prescriber’s Office Address: ___________________________________
Suite #: _____________ City: _________________________________________ State: _____________________ Zip Code: ____________________
DEA/State License #: _____________________________________________ NPI #: _______________________________________________________
Email: ___________________________________________________________________________________________________________________________
SECTION 2: Patient History
Patient’s Name: __________________________ Date of Birth: _______/_______/_______ No known allergies
Allergies: ______________________________________________ Current Medications: __________________________________________________
SECTION 3: Prescription
Medication #1 Name: _____________________ Strength: _________ If an injectable, please specify: Pen Syringe Cartridge
Directions: _________________________________________________________________________________________________________________
Quantity: ___________________ 90 Days Supply* Other: ____________ Refill: 1 year Other: ______________________
_____________________________________________________________________________________________________________________________
Medication #2 Name: _____________________ Strength: _________ If an injectable, please specify: Pen Syringe Cartridge
Directions: _________________________________________________________________________________________________________________
Quantity: ___________________ 90 Days Supply* Other: ____________ Refill: 1 year Other: ______________________
*Prescriptions may be supplied in
NOTE: Please be aware, if a Prior Authorization (PA) is required for the Novartis product(s) requested, you will need to provide that PA # and date of approval, or attach a copy of the denial letter. If this is a January renewal, you will need to process and forward a new PA. If we do not receive this information with the HCP portion of the application there may be a delay in processing for your patient.
SECTION 4: Prescriber Certification and Signature
Health Care Provider Authorization
I certify that the above therapy is medically necessary and that this information is accurate to the best of my knowledge. I certify that I am the physician who has prescribed the drug identified above to the previously identified patient. For the purposes of transmitting this prescription, I authorize NPAF and its affiliates, business partners, and agents to forward, as my agent for these limited purposes, this prescription electronically, by facsimile, or by mail to the appropriate dispensing pharmacies.
I certify that any medication received will be used only for the patient named on this form and will not be offered for sale, trade, or barter. Further, no claim for reimbursement will be submitted concerning this medication, nor will any medication be returned for credit. I acknowledge that NPAF is exclusively for purposes of patient care and not for remuneration of any sort. I understand that NPAF may revise, change, or terminate programs at any time.
Novartis Patient Assistance Foundation, Inc. (NPAF) Health Care Provider Authorization
I have read and agree to the Health Care Provider Authorization and authorize the above prescription:
PRESCRIBER SIGNATURE:__________________________________________ |
DATE: ______/______/________ |
(REQUIRED) |
(REQUIRED) |
Form Characteristics
| Fact Name | Description |
|---|---|
| Contact Information | For assistance, call 1-(800)-277-2254 or fax your documents to 1-(855)-817-2711. The Novartis Patient Assistance Foundation, Inc. operates Monday-Friday from 8:00 a.m. to 8:00 p.m. Eastern Time. |
| Eligibility Criteria | To qualify for assistance, applicants must be U.S. residents, meet specific income requirements, and have limited or no prescription coverage. |
| Application Process | Patients must complete Sections 1-5 of the Patient Application, providing personal, insurance, and income information to determine eligibility. |
| Electronic Income Verification | Patients have the option to choose an electronic income check, which does not affect their credit score, by checking the relevant box on the application. |
| Patient Authorization | Signing the Patient Authorization allows the sharing of personal information among health care providers, insurers, and the Novartis Patient Assistance Foundation for program administration. |
| Prior Authorization Requirement | If a patient's insurance requires it, the health care provider must obtain a Prior Authorization and include it with their application section. |
| State-Specific Laws | Eligibility verification and patient authorization procedures are governed by both federal laws and applicable state laws regarding patient privacy and healthcare practices. |
Guidelines on Utilizing Novartis Patient Assistance
Completing the Novartis Patient Assistance form is an essential step towards receiving the support you may need. Here are the necessary steps to successfully fill out the application.
- Visit www.PAP.Novartis.com to access the Patient Assistance form.
- Start with Patient Section 1. Fill in your personal information accurately, including your name, date of birth, and address.
- In Patient Section 2, indicate if you have insurance. If so, include a copy of both the front and back of your insurance cards.
- For Patient Section 3, provide proof of your household’s gross income. Choose one of the following options:
- Check the box if you consent to an electronic income verification. Note: You must be 18 years or older to select this option.
- If you prefer to send documents, include your most recent tax return, three months of paycheck stubs, W-2 form, or Social Security statement (1099).
- In Patient Section 4, decide if you want to receive reminders and information via automated calls or texts. If yes, check the box to consent.
- In Patient Section 5, read the Patient Authorization carefully, then sign and date the form to allow application processing.
- Collaborate with your healthcare provider to complete their sections on the application.
- If your insurance requires prior authorization, ensure your healthcare provider includes that with the application.
- Submit the completed application by either faxing it to 1-(855)-817-2711 or mailing it to NPAF at P.O. Box 52029, Phoenix, AZ 85072-2029.
Keep a copy of your completed application for your records. For further questions, you can reach NPAF at 1-(800)-277-2254, Monday to Friday, from 8:00 a.m. to 8:00 p.m. Eastern Time.
What You Should Know About This Form
What is the Novartis Patient Assistance Foundation (NPAF)?
The NPAF is a program designed to assist patients who are unable to afford their prescribed Novartis medications. The foundation provides access to necessary medications for eligible individuals, ensuring that financial barriers do not prevent patients from receiving essential treatments.
Who is eligible for the NPAF program?
To qualify for assistance, patients must meet several criteria. They need to be a resident of the United States, have limited or no prescription drug coverage, and meet specific income requirements. It’s crucial to visit www.PAP.Novartis.com for detailed information regarding these income thresholds and eligible medications.
How can I apply for assistance?
Applying for assistance involves completing the NPAF Patient Application, which consists of five sections. Applicants must provide personal information, insurance details, and proof of income. Once the application is filled out, it should be submitted via fax or mail to the respective addresses, allowing NPAF to assess eligibility.
What documents are required for income verification?
Patients have options for income verification. They may choose an electronic income check, which is faster and won’t affect credit scores, provided they are 18 years or older. Alternatively, they can submit recent financial documents such as tax returns or paycheck stubs as proof of income.
Can I receive text message reminders for medication refills?
Yes, enrolled patients can opt to receive text message reminders for medication refills. This feature is designed to help manage prescriptions effectively. Patients must consent to this communication method by checking the relevant box on the application form.
What should I do if my personal information changes?
If there are changes to your personal information, it’s important to notify NPAF promptly. This includes updates to your phone number, address, or income information. Timely communication ensures that you continue receiving support without interruption.
How can I contact NPAF for more information?
For additional queries, you can reach the Novartis Patient Assistance Foundation at 1-(800)-277-2254 during business hours, which are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern Time. Alternatively, you can fax your questions to 1-(855)-817-2711 or visit their website at www.PAP.Novartis.com for more comprehensive resources.
Common mistakes
Completing the Novartis Patient Assistance form can be a crucial step in securing the necessary medications for individuals in need. However, various mistakes can occur during the process, sometimes hindering timely assistance. One common error is neglecting to fill out Patient Section 1 completely and accurately. Missing or incorrect information can delay the application review, as the foundation relies on those details to determine eligibility. It is essential to take the time to ensure every field is filled out correctly.
Another mistake frequently made involves the submission of insurance information. Some applicants may overlook the requirement to include a copy of both the front and back of all insurance cards. This document is vital for verifying coverage. Failure to provide this information may result in a denial or delay of assistance.
Inadequate proof of income submission represents a significant error. Patients must provide proof of their household’s gross income to qualify. Many people opt for the electronic income verification method without understanding that they must explicitly check the box granting permission for this process. If this step is missed, the application could be stalled due to insufficient income verification.
Moreover, skipping the Telephone Consumer Protection Act (TCPA) consent process is another common oversight. While it is optional, allowing NPAF to contact you via automated calls or texts can simplify communication about your enrollment and medication refills. Patients should carefully consider whether this option would facilitate their experience and, if so, check the appropriate box.
Incomplete reading or misunderstanding of the Patient Authorization may further complicate the process. Patients must thoroughly read the authorization page and understand what it entails before signing. Misunderstandings here could lead to delays in processing the application, as signing an authorization that one does not fully comprehend can jeopardize the applicant's privacy.
Some applicants may also neglect to work closely with their healthcare providers (HCPs) to ensure their sections are completed correctly. If HCPs are required to obtain a Prior Authorization, their failure to include this information could lead to further delays. Open communication between patients and their HCPs is necessary to ensure that all required documents are included.
Additionally, a common error occurs when applicants fail to double-check their contact information. Providing an incorrect phone number or email address can lead to missed communications regarding application status or medication management. It is imperative to ensure that this information is accurate to avoid any unnecessary complications.
Another frequent mistake is not retaining a copy of the completed application. Applicants should keep a record of all submitted documents. This step is vital for reference in the event of a follow-up or if there is a need to confirm what was submitted.
Finally, some individuals may overlook submission deadlines or the hours of operation for the NPAF. Being mindful of these details can ensure smoother communication and processing timelines. It is advisable to submit the application well before any required deadline to account for potential processing delays.
By being aware of these common mistakes and taking proactive steps to avoid them, applicants for the Novartis Patient Assistance program can streamline the process and increase their chances of receiving the assistance they need.
Documents used along the form
The Novartis Patient Assistance Form plays a crucial role in helping patients access necessary medications. In many cases, individuals may need to complete additional forms to ensure a smooth application process. Below is a list of commonly used documents that complement the Novartis Patient Assistance form, providing essential information and support to patients seeking assistance.
- Proof of Income Documentation: This may include the most recent tax return, pay stubs, W2 forms, or Social Security statements. Providing accurate income information helps verify eligibility for assistance programs.
- Insurance Cards: A copy of both the front and back of all insurance cards is required if the applicant has insurance. This helps the Novartis Patient Assistance Foundation verify coverage and benefits.
- Patient Authorization Form: This document allows for the disclosure of personal health information to the Novartis Patient Assistance Foundation. It is essential for processing applications and communicating with healthcare providers.
- Prescriber Application: Submitted by the healthcare provider, this form includes patient information, prescriptions, and medical necessity certification. It often requires the prescriber’s signature to validate the application.
- Prior Authorization Documentation: If insurance requires prior authorization for a prescribed medication, this documentation must be provided by the healthcare provider. It ensures that the patient can access their required medication without unnecessary delays.
- FCRA Consent Form: This optional form allows for electronic income verification through credit profile checks. Patients must provide specific consent to initiate this process.
- TCPA Consent Form: This form grants permission for the Novartis Patient Assistance Foundation to use automated systems to contact patients about their applications, refills, and other important updates.
- Clinical Summary: A summary of the patient’s medical history and treatment plans may be needed to provide additional context about the necessity of the prescribed medications.
- Verification of Residency: Proof of residency may be required, such as a utility bill or lease agreement, to confirm the patient's U.S. residency status for eligibility considerations.
Gathering these documents with the Novartis Patient Assistance form can help streamline the application process. Completing all necessary paperwork accurately increases the likelihood of swift assistance, ultimately supporting patients in accessing the medications they need.
Similar forms
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Medicare Extra Help Application: This document assists low-income individuals in obtaining help with Medicare prescription drug costs. Similar to the Novartis Patient Assistance form, it requires personal information, financial details, and documentation of income. Both forms aim to evaluate eligibility for assistance programs based on income and healthcare needs.
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Social Security Administration Application for Benefits: Applicants seeking financial support from the Social Security Administration must complete a comprehensive form detailing their personal information, financial background, and medical conditions. Like the Novartis form, it requires patients to validate their eligibility for assistance through documentation and signatures.
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Patient Assistance Program (PAP) Applications from Other Pharmaceutical Companies: Many pharmaceutical companies offer their own patient assistance programs with similar application processes. Patients fill out forms that require insurance details, income information, and personal verification, mirroring the requirements found in the Novartis Patient Assistance form.
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State Medicaid Application: This application connects eligible low-income individuals and families with Medicaid healthcare coverage. It includes required sections for personal information, household income, and insurance details, creating a parallel with the Novartis form in determining qualification for healthcare assistance.
Dos and Don'ts
When filling out the Novartis Patient Assistance form, here are some important do's and don'ts to keep in mind:
- Do ensure that all your personal information is accurately filled out in Patient Section 1. This is crucial for eligibility determination.
- Do include copies of both the front and back of your insurance cards in Patient Section 2, if you have insurance coverage.
- Do provide proof of income as outlined in Patient Section 3, choosing either the electronic income check or financial documents.
- Do sign and date the Patient Authorization page in Patient Section 5, as it is needed for processing your application.
- Don't skip any sections or provide incomplete information, as this can slow down your application process.
- Don't forget to discuss any required Prior Authorization with your healthcare provider, if you have insurance.
- Don't assume prior applications or documentation from previous years can be reused; fresh information is often necessary.
- Don't neglect to keep a copy of the completed form for your records before submitting it through fax or mail.
By following these tips, you can help ensure a smoother application process and increase your chances of receiving the assistance you need.
Misconceptions
Misunderstandings can lead people to avoid essential resources. Here are some common misconceptions about the Novartis Patient Assistance form:
- It’s only for low-income patients. Many believe this program is exclusively for those with very low income. However, it also assists individuals with limited insurance coverage and those who may be above the poverty line yet struggle to afford medications.
- You need to be a U.S. citizen. Some think that only citizens can apply. In reality, the program is open to all U.S. residents, regardless of citizenship status.
- You can’t apply if you have insurance. It's a common notion that having any insurance disqualifies you. However, the form is available for those with some insurance who still face high out-of-pocket costs.
- The application process is too complicated. While it may seem daunting, the steps are straightforward. Clear instructions guide applicants through each section, making the process manageable.
- Only specific medications are covered. Some believe that Novartis only provides assistance for a limited range of medications. This is not true, as the program lists a variety of approved medications on their website.
- Your credit score will be affected. There’s a misconception that completing the income check portion will impact credit ratings. The truth is, the electronic income check is designed solely for verification without any effect on credit scores.
- Your personal information isn’t safe. People often worry about sharing personal details. However, the program has strict privacy measures in place to protect your information.
- Once you apply, you can't change your mind. Many think applying means they have to continue with the program. In fact, participants can revoke their authorization at any time if they choose not to proceed.
- You can't get assistance for multiple medications. It's a myth that only one medication can be requested per application. Patients can apply for assistance with more than one medication if needed.
Understanding these misconceptions can help you make informed decisions about your healthcare options. If you have questions or need more details, contact the Novartis Patient Assistance Foundation directly for clarity.
Key takeaways
Here are important points to remember when filling out and using the Novartis Patient Assistance form:
- Eligibility Requirements: To qualify, patients must be U.S. residents, meet income criteria, and have limited or no prescription coverage.
- Complete Sections: Fill out Patient Sections 1-5 accurately to help expedite the review process.
- Insurance Details: If you have insurance, provide copies of both the front and back of your insurance cards.
- Income Verification: You can choose between electronic income verification or submitting financial documents like tax returns or pay stubs.
- Automated Reminders: Consider consenting to receive text reminders for refills if enrolled in the program.
- Patient Authorization: Read, sign, and date the Patient Authorization section to allow data processing and communication.
- Health Care Provider Role: Collaborate with your health care provider to complete their sections of the application.
- Prior Authorization: If your insurance requires it, your health care provider must obtain and submit a Prior Authorization with the application.
- Submission Methods: Once completed, fax or mail your application to the provided addresses.
- Keep Copies: Retain copies of all submitted forms for your records.
Utilizing these key takeaways can enhance your experience with the Novartis Patient Assistance program.
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