Fillable NeedyMeds Thank you for downloading this patient assistance (NeedyMeds)

Fill Online, Printable, Fillable, Blank NeedyMeds Thank you for downloading this patient assistance (NeedyMeds) Form

Use Fill to complete blank online NEEDYMEDS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

NeedyMeds Thank you for downloading this patient assistance (NeedyMeds)

On average this form takes 9 minutes to complete

The NeedyMeds Thank you for downloading this patient assistance (NeedyMeds) form is 5 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your NeedyMeds forms online.

BROWSE NEEDYMEDS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program
will help you get the medicine you need.
REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds.
Did you know that NeedyMeds has thousands of other free resources?
Here’s a look at more ways we can help you save money on medicine and healthcare costs. Each one
can be found under the “Patient Savings” tab on our website:
• Diagnosis-Based Assistance — NeedyMeds lists thousands of assistance programs for almost any
health condition. If you are going through chemo treatment for cancer, there are programs that can
help with wig costs and scalp-cooling products. We also list resources for free diabetes testing
supplies, caregiver lodging support, and much more.
• Free, Low Cost, and Sliding Scale Clinics — This popular collection contains information on
18,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It’s a great
resource if you need affordable medical treatment and don’t know where to go.
• Coupons, Rebates & More — You can use the NeedyMeds website to find nearly 2,000 cost-saving
opportunities for both prescription and over-the-counter drugs and medical supplies.
• Medical Transportation — Need help getting to the doctor’s office or medical facility? You may be
eligible for financial assistance if you meet certain requirements.
Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free,
anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount
card has saved patients over $244,000,000. Check out the next page to learn more.
Feel free to call our toll-free helpline if you have any questions. You can reach us at 1-800-503-6897
Monday-Friday, 9am-5pm Eastern Time.
Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs
of your healthcare.
Rich Sagall, MD
Richard J. Sagall, MD
President, NeedyMeds
www.needymeds.org
NeedyMeds
Find help with the cost of medicine
NeedyMeds.org
P.O. Box 219
Gloucester, MA 01931
Helpline
: 1-800-503-6897
Email: info@needymeds.org
www.needymeds.org
Form from www.needymeds.org
BIN: 020750
RX PCN: NMeds
RX GRP: PDFPDF
ID: NMNA019309901930
This is a drug discount program, not an insurance plan.
Clip the card and save
• Save up to 80% on medications*
• Use at over 65,000 pharmacies
nationwide including all major chains
• Share the card with friends and family
• Use the card as oen as needed
• Free, no fees or registration
• Never expires
• A drug isn’t covered by your insurance
• Your insurance has no drug coverage
• You have a high drug deductible
What if I have insurance?
Anyone can use the card, but it can’t be combined with state or federal insurance.
You can use the card instead of insurance if:
• You have met a low medicine cap
• The card offers a better price than your copay
• You are in the Medicare Part D donut hole
What will receive a discount?
All prescription medications are eligible for savings, including over-the-counter medicines
and medical supplies written as a prescription, as well as human-equivalent pet medications
with a prescription by a veterinarian.
You can also save up to 40% off durable medical equipment, including canes, crutches, splints,
incontinence supplies and more. You can also save on diabetic supplies such as glucose meters,
test strips, lancets and diabetic shoes. Visit www.needymeds.org/dme to learn more.
The card is not valid in combination with insurance plans, including Medicare, Medicaid or any state
or federal prescription insurance. The card can be used only if you decide not to use your
government-sponsored drug plan for your purchases.
Patient: You may use this card at any of over 65,000
participating pharmacies to save on all prescription medicines.
You cannot use this card with Medicare including part D,
Medicaid, or any other state or federal programs unless you
choose not to use your government-sponsored program. In
addition, you cannot use this card with any health insurance
program, but you can use it in place of your insurance if the
card offers a better price. For questions call 1-888-602-2978
or visit www.drugdiscountcardinfo.com.
NeedyMeds Drug Discount Card
www.needymeds.org
DRUG DISCOUNT CARD
NeedyMeds
NeedyMeds.org
To obtain a plastic drug discount card, send a self-addressed, stamped envelope to:
NeedyMeds Drug Discount Card
PO Box 219
Gloucester, MA 01931
Customer Care
1-888-602-2978
Pharmacist: Administered by Medical Security Company, LLC,
Tucson, AZ.
Pharmacy Help Desk: 1-800-404-1031.
* Average savings of 60%, with potential savings of up to 80% or more (based on 2018 national program savings data).
All prescription medications are eligible for savings.
This is a drug discount program, not an insurance plan. Discounts are available exclusively through
participating pharmacies. The range of the discounts will vary depending on the type of prescription and
the pharmacy chosen. This program does not make payments directly to pharmacies. Users are required to pay
for all prescription purchases. Cannot be used in conjunction with insurance. You may call 1-888-602-2978
with questions or concerns or to obtain further information.
2611 Internet Blvd, Suite 105 Frisco, TX 75034
877-968-7233 ● Fax 214-570-3621 ● www.mygooddays.org
Private and Confidential when completed
Page 3 of 5
V08262019
Please review enrollment information below. Complete form by filling in missing information. Make any corrections by writing
changes next to the information provided.
Date:
How much can you afford for this medication?
You may be responsible for any remaining balance
Good Days
does not cover.
ID or SSN:
PATIENT INFORMATION
Patient's Name:
Birth Date:
Alternate Contact:
Relationship:
Mailing Address:
Home phone:
Cell Phone:
Work Phone:
Ext:
E-mail Address:
INCOME INFORMATION
Number of people in household:
PHYSICIAN INFORMATION
Physician Name:
Physician Phone:
Office Address: (if known)
Physician NPI:
DIAGNOSIS INFORMATION
Diagnosis:
Medication:
Pharmacy:
Pharmacy Address or Phone: (if known)
MAJOR MEDICAL INSURANCE INFORMATION
Insurance Name:
ID#:
Group #:
Phone:
DRUG CARD INFORMATION
Insurance Name:
ID#
BIN:
PCN:
Phone:
Is this a Medicare, Federal or State funded insurance plan?
Yes No (circle applicable answer)
***THIS PAGE MUST BE RETURNED***
Reset Form
Downloaded from NeedyMeds.org
2611 Internet Blvd, Suite 105 Frisco, TX 75034
877-968-7233 ● Fax 214-570-3621 ● www.mygooddays.org
Private and Confidential when completed
Page 4 of 5
V08262019
*Metastatic Cancer Diagnoses Only
For patients in a metastatic cancer fund: If your physician has prescribed a drug to treat your metastatic cancer that is not
on Good Days’ formulary, please contact us. We may be able to cover the prescribed drug if we receive additional
documentation showing that the drug otherwise meets our criteria. For our metastatic cancer funds, Good Days will cover
all drugs approved by the Food and Drug Administration (the “FDA”) that treat the type of cancer that is the basis of the
disease fund into which you have been accepted. For example, if you have metastatic breast cancer, Good Days will cover
all drugs that are approved by the FDA to treat breast cancer, not just those drugs that the FDA has expressly approved for
the metastatic stage of breast cancer.
Declaration
You attest and certify to Good Days and its agents that the information provided in your application is complete and accurate.
You understand that, and consent to, your reported financial information being verified by an audit as deemed necessary
by Good Days. Good Days, and its authorized third party agents, such as credit monitoring companies, may use your
demographic information, including but not limited to your social security number, date of birth, name, and address in order
to estimate your income in conjunction with the eligibility process. You understand that Good Days, and its authorized third
party agents, reserve the right to ask for additional documents and information at any time. As a soft credit inquiry, this
does not impact your credit score.
You further understand that any false or incomplete information provided by you to Good Days could unduly harm your
application process, Good Days, its reputation, and its tax exempt status. You also understand that any financial assistance
provided to you by Good Days may be recouped, if Good Days becomes aware of any inaccurate information or fraudulent
activity relating to your application or the assistance provided to you. You understand that you are free at any time to switch
providers, practitioners, suppliers, or treatments within the Good Days formulary for your diagnosis without affecting your
continued eligibility for assistance.
You understand that you are not guaranteed or promised assistance. Any assistance Good Days may provide is limited to
the terms and conditions established by Good Days. Good Days reserves the right at any time, and for any reason without
notice, to modify the eligibility criteria or modify or discontinue any assistance.
Limitation of Liability:
You agree that Good Days, our sponsors, and our donors shall not be liable for any damages of any kind, without limitation,
arising out of or in connection with you receiving financial assistance, co-pay relief, or other value-added benefits or services
provided as a part of this program.
Patient Attestation:
You agree to be fully compliant in taking the drug for which financial assistance is being provided in accordance with your
doctor’s directions.
By signing below you agree that you have read, understand and agree to adhere to the above statements
***THIS PAGE MUST BE RETURNED***
Signature of Individual or Individual’s representative
Date
Print name of Individual’s representative: (If applicable)
Authorized Relationship or
Authority to Act (If applicable)
Downloaded from NeedyMeds.org
2611 Internet Blvd, Suite 105 Frisco, TX 75034
877-968-7233 ● Fax 214-570-3621 ● www.mygooddays.org
Private and Confidential when completed
Page 5 of 5
V08262019
Terms of the Consent Pertaining to the Disclosure of your Personal Information
In order for you to receive assistance through Good Days, you authorize your physicians, pharmacies and
insurance companies to disclose to Good Days and its applicable contractors, employees, agents and other
representatives your personal information. In addition you authorize Good Days to use and disclose your
personal information to Good Days’ agents, third parties acting on its behalf, credit monitoring companies, or any
of your healthcare providers.
Your personal information may include, but not be limited to, your name, address, phone number, email address,
date of birth, social security number, insurance status and numbers, amount of financial assistance allocated
and dispensed, diagnosis information, and treatment information.
You consent to the disclosure of your personal information for the following purposes: (i) to enable Good Days
to determine whether you are eligible and qualify for financial assistance for any medication(s); (ii) to enable
Good Days to provide financial assistance to you for your medication(s); (iii) to refer you to, or to determine
your eligibility for, other programs, foundations or alternate sources of funding or coverage for your healthcare
costs, products and services; (iv) to facilitate the audit or review of Good Days’ operations; and (v) to enable
Good Days to manage its patient assistance programs.
You understand that your personal information that is disclosed may be re-disclosed by the recipient and no
longer protected by federal or state privacy regulations and laws. You consent to Good Days re-validating your
personal information. You consent to Good Days electronically disclosing your personal information to third
parties as permitted or required by law.
You may revoke this consent at any time by mailing a signed letter of revocation to Good Days’ Privacy Officer
at 2611 Internet Blvd, Suite 105 Frisco, TX 75034 or faxing the written consent to Good Days’ Privacy Officer at
the following fax number: (214) 570-3636. Revoking this consent will not have any effect on actions that Good
Days took in reliance on the consent before it received notice of your revocation. If you revoke this consent, you
will not be able to receive future assistance through Good Days. However, your applicable healthcare providers
and insurance companies, who are disclosing the information to Good Days, may not condition treatment,
payment, enrollment or eligibility for benefits on whether the individual signs this consent.
This consent expires six years from the date that you last receive assistance from Good Days, if not revoked
sooner.
***THIS PAGE MUST BE RETURNED***
PLEASE VISIT WWW.MYGOODDAYS.ORG/APPLY TO PRINT A COPY OF THE CONSENT
Signature of Individual or Individual’s representative
Date
Print name of Individual’s representative: (If applicable)
Authorized Relationship or
Authority to Act (If applicable)
Downloaded from NeedyMeds.org
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

NeedyMeds Thank you for downloading this patient assistance (NeedyMeds)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document