MEDICATION ASSISTANCE PROGRAM (MAP)

Application Packet

This packet of information and forms will help you apply for local medication assistance program. It is important that you

fill this paperwork out completely and have the proper documents to turn in for consideration. Failure to do so will delay

the enrollment process. If you have questions, you may contact your local representative at the numbers below. MAP

is not affiliated with the eligibility assistance program. Thank you.

Checklist for Applying for Medication Assistance

☐ Complete the MAP application. (see attached)

☐ Provide specific income documentation. Refer to pages 3 & 4 of application for details.

☐ Provide a copy of a valid Photo ID (Examples include: current driver’s license or State ID issued by DMV)

☐ If you have Medicare Part D (prescription coverage), you will need to provide the following:

☐ A copy of the front and back of the Medicare Card and Medicare Part D (prescription

coverage) card .

☐ A copy of Explanation of Benefits (EOB) that details out of pocket prescription

expenses for the current calendar year . Get this from your insurance company. You can also provide a

print-out form from your local pharmacy (dated 1-1 current year until present date).

☐ If you have a Low Income Subsidy (LIS) denial letter, please attach a copy with your

application.

Please return your completed MAP application to your local MAP office by mail, or deliver it in person (see page one of

application for addresses). You may also return it to your prescriber’s office for processing. Don’t forget to keep a copy

of this packet for your records.

CMAP (Roanoke) 540-981-7647

NRVMAP (Radford) 540-731-2414

GMAP (Giles) 540-922-4282☐

INFUSION MEDICATION/CMAP 540-981-7506

MEDICATION ASSISTANCE PROGRAM (MAP)

These programs are supported by Carilion Clinic, but applications are approved by other agencies.

Patient Application – page 1 of 7

Please fill out this application completely and mail it to the location nearest your home. You may also

fax it or deliver it in person (best to call ahead for office hours).

GILES MAP ROANOKE MAP INFUSION MEDICATION

159 Hartley Way 1906 Belleview Ave 1906 Belleview Ave

Pearisburg, VA 24134 Ground Floor

NRV MAP

2900 Lamb Circle

Christiansburg, VA 24073

Phone: 540-731-2414

Fax: 540-731-2413

Ground Floor

Phone : 540-922-4282 Roanoke, VA 24014 Roanoke, VA 24014

Fax: 540-921-1824 Phone: 540-981-7647 Phone: 540-981-7506

Fax: 540-344-0301 Fax: 540-343-1003

MEDICATION ASSISTANCE PROGRAM (MAP)

Date ______________________________ Email Address _____________________________________

Name _______________________________________________________________________________________

(First) (Middle) (Last)

Social Security # _________-____________-__________ Date of Birth __________________________________

MM DD YYYY

Home phone number ____________________________ Cell Phone ______________________________

(CIRCLE ONE)

Mailing address:

Street Address/P.O. Box _______________________________________________________________________

City _______________________County _________________State __________________ Zip _______________

Physical address (if different from above):

Street Address ______________________________________________________________________________

City _______________________County _________________State __________________ Zip _______________

Circle your answer:

 Is English your first language? YES or NO

 If NO, please list first language ______________ Do you need language assistance? YES or NO

 Are you a U.S. Military Veteran? YES or NO

Referred by: ___________________________________________________________________



GENDER Female Male

ETHNICITY

African/

American

Asian Caucasian Hispanic

Native

American

Other

MARITAL STATUS Single Married Separated Divorced Widowed

U.S. CITIZEN? Yes No

———————————————————————————————————————————————————-

Patient Application – page 2 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

 Employment Status (circle one): Employed Unemployed (short term) Unemployed (long term)

Self-employed Retired Student Disabled

 Are you legally disabled (receive a Social Security disability check)? YES or NO

 If YES, since what date: _________-________-_________

 Who is your family medicine physician? ______________________ Phone___________________

Please list your mediations, dosage, the reason for taking the medication, and the prescriber

Medication/Strength

Dosage

(How often do

you take it)

Reason for taking

(diagnosis)

Prescriber

(Health care

provider)

List Medication Allergies : ________________________________________________

_______________________________________________________________________

Patient Application – page 3 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

Patient Name:

DOB:

Adults

Children under 18

Years Old

Total

Number of People In

Your Household

Use the chart below to list every member of your household. Include income from ALL sources including:

wages, Social Security, disability, retirement, pension, Veteran’s benefits, child support, self-employment,

interest, dividends, etc.

Name of Household

Member

Age Type of

Income

Gross Amount How often do you

receive this income?

Patient:

Income Documentation

Did you file a Federal Income Tax Return for last year? YES or NO (circle one)

If YES, provide a copy of your Federal Income Tax Return for yourself and your spouse if married

or if you are claimed on someone’s taxes. If self-employed, include Schedule C.

If NO, complete Tax Form 4506-T (attached at the end of this application), to verify that you did

not file a Federal Income Tax Return. If you are married and your spouse did not file a

Federal Income Tax Return, your spouse needs to complete the spouse’s portion of the

form.

Do you, your spouse or any of your dependents (under age 18) receive Social Security or

Social Security Disability benefits? YES or NO (circle one)

If YES, provide a copy of your Current Benefit Verification Statement. Please note that copies of

your bank statement are not acceptable. If you need to obtain a copy of your Current

Benefit Verification Statement, you may visit your local Social Security office or

call 800-772-1213.

Do you or anyone in your household receive any other type of income not listed above?

YES or NO (circle one)

If YES, provide documentations. Bank statement cannot be accepted (i.e. 1099, etc).

*Please note that MAP may not obtain any medications on your behalf if the correct income

documentation is not provided. If you have any questions about what type of documentation

is required, contact any of the listed MAP offices.

Patient Application – page 4 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

If you have Medicare, please answer the following questions:

1. Have you applied for the Low Income Subsidy, also known as Extra Help, to help with the

cost of a Medicare Part D prescription drug plan? YES or NO

2. If you have Medicare Part D please provide a copy of your out of pocket statement.

Are you currently using drug manufacturer medication assistance programs?

YES or NO

If YES, what drug companies do you work with ________________________________

If YES, what drugs do you get from these programs? ____________________________

What retail pharmacy do you use to buy your medications?________________________

Insurance

Mark in the appropriate column below to indicate if you have any of the

following types of coverage and provide front/back copy of any card with yes answer:

TYPE YES NO

Medicare Part A

Medicare Part B

Medicare Part D (Prescription Coverage)

Medicaid QMB Extended (with Prescription Drug Coverage)

Medicaid (Spend Down)

Veteran’s Assistance

Commercial/Employer’s Insurance

Medication Assistance Program Signature Waiver

I authorize designated representatives of the Carilion Medication Assistance Program to

sign my name on the necessary pharmaceutical forms that may be required for ordering

my needed medications. The purpose is to expedite the ordering process by eliminating

having to mail forms to the patient for signatures.

Patient Signature: ____________________________________________________________

Carilion Medication Assistance Program

Participation & Consent to Release Information

I authorize Carilion Clinic and any Carilion Medication Assistance Advocate (“Carilion”)

to help me obtain free or reduced rate prescribed medications for use in my treatment from

independent or manufacturer patient assistance programs (“Patient Assistance Program”).

I authorize Carilion to complete necessary form(s), using information supplied by me, and to sign

my name on all form(s) required for participation in a Patient Assistance Program(s) for

pharmaceuticals that I have been prescribed.

I authorize Carilion, Patient Assistance Programs, and any insurer or healthcare provider to

disclose to any Patient Assistance Program financial and insurance records and information,

personal identifying information, and necessary medical records and information, as necessary for

my enrollment or participation in a Patient Assistance Program. I acknowledge that the released

information may contain alcohol, drug abuse, psychiatric treatment, sexually transmitted disease

treatment, HIV testing, HIV results or AIDS information and I hereby authorize and consent to

this disclosure. _______ (Initial) There is a potential that information disclosed may be redisclosed

by the recipient and no longer protected by law.

I grant the Patient Assistance Program(s), pharmaceutical companies and manufacturers the

right to investigate all claims made on my behalf and agree to notify them of any change in my

insurance eligibility or financial status. I understand that eligibility under a Patient Assistance

Program is subject to the pharmaceutical companies’ approval and my continuing compliance with

all eligibility requirements.

I have read, understand and agree to all of the above. This consent shall terminate on the

earlier of: i) my no longer being eligible to participate in the Carilion Medication Assistance

Program; (ii) my electing to no longer participate in the Carilion Medication Assistance Program

and notifying Carilion; or (iii) my rescinding this consent in writing and notifying Carilion. A

photocopy or faxed copy may be used in place of the original.

_______________________________________________

Signature

_______________________________________________

Print Name

_______________________________________________

Date of Signature

Patient Application – page 5 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

Patient Application – page 6 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

MAP Program Guidelines – Page 1 of 2

Carilion Clinic employs a Medication Assistance Program team to organize applications for patients

needing medications, and who qualify for indigent programs offered by pharmaceutical companies. By

signing these guidelines, you are agreeing to abide by the following terms:

1. I certify that the information provided by me represents correct and accurate data to the best of my

knowledge and that the information is given freely so that I can be considered for the Medication

Assistance Program (MAP). I understand that false or misleading information or declaration(s) by

me to the MAP will make me ineligible for MAP. I further understand that a false or misleading

declaration by me may result in pharmacy assistance adjustments for which I would not otherwise

have qualified and may subject me to civil and criminal penalties.

2. I understand that this is not a reimbursement program. I am solely responsible for any medications

I have previously purchased and may need to purchase in the future.

3. I understand that there may be delays in getting my medications and if I should run out of

medication before I receive it through MAP, I am solely responsible for obtaining my medications

when they arrive. Additionally, should there be any medications that are unavailable through the

program, I understand it is my responsibility to obtain those medications without reimbursement

from the program. The MAP offices cannot guarantee the provision of medications obtained

through the medication assistance programs sponsored by various drug manufacturers. I

understand that I have the option of purchasing medications at the retail pharmacy of my choice.

4. I must notify the MAP staff in the event that my medical provider discontinues any of my

medications, adds additional medications, changes a dose or the number of times that I take my

medication each day. Failure to provide notification of medication changes may result in an

interruption of my medication.

5. It will be my responsibility to replace medications that are lost or stolen after I have obtained them

from the program.

6. I understand that I should be notified when my medication is delivered to the physician’s office.

It is my responsibility to pick up my medications once I am notified. Failure to pick up my

medications within one (1) month of delivery could result in my medications no longer being

available.

7. It is my responsibility to notify the MAP staff in a timely manner when I need more medication to

be ordered through the program. I must notify MAP when medication is received whether at a

retail pharmacy, physician office or home address. Failure to give enough notice may result in me

having to pay for my medication at the retail pharmacy of my choice.

8. I agree to follow my medical provider’s instructions regarding my care, including maintaining

routine medical appointments, appropriate labs, EKG, x-rays and any other instructions necessary

for my care.

HIPAAPrivacy / Confidentiality Permission Form

Patient Application – page 7 of 7

MEDICATION ASSISTANCE PROGRAM (MAP)

One of the goals of the Medication Assistance Programs (MAPs) is to provide you with medication

while maintaining your confidentiality. Please list family members or individuals who may discuss

your medication needs with MAP representatives.

MAP representatives will only discuss medication needs with the individuals listed below.

If this information changes while you are enrolled in the MAP, notify our program.

MAP Program Guidelines—page 2 of 2

9. I must notify the MAP staff immediately in the event of any changes regarding my household such as

a change of address, telephone number, household status (i.e. marriage, divorce), number of

people in household, change of income, new insurance, etc.

10. I must complete the annual re-enrollment process. I must also provide income documentation upon

request.

11. There are occasions when an application the MAP submits to a drug manufacturer is rejected for any

number of reasons. The rejection may be mailed to my home address. It is my responsibility to notify

the MAP of any rejections so the program may appeal and resubmit the application on my behalf.

I have read and understand pages one and two of the MAP Program Guidelines and agree to follow

all of the guidelines for the duration of any assistance I receive from the MAP. I understand that any

violation of any part of the policy may make me ineligible for services provided by the MAP.

_______________________________________________

Signature Date

_______________________________________________

Print Name

Name Relationship Telephone Number