VEL214CDNY7528 P_VRAP Enrollment Form (V-11

Please complete the information below and fax to the VELCADE Reimbursement Assistance Program at (800) 891-9843 or mail to PO Box 52100, Phoenix,
AZ 85072. Questions regarding this application may be addressed to the VELCADE Reimbursement Assistance Program at (866) 835-2233, option 2.
Requested Program Service:
 Patient Assistance Program Enrollment
 Transportation Assistance*
 All
Patient Information
Insurance Information
Patient Name: ______________________________________________
Do you have any type of health insurance, including public programs such
as Medicare, Medicaid, or any other assistance programs?  Yes  No
(If yes, please complete below)
Date of Birth: _________________ SSN: ________________________
Mailing Address: ____________________________________________
City: _____________________State: ______ ZIP: _________________
Telephone: ________________________________________________
Have you ever applied for Medicaid?  Yes  No
Primary Insurance: _________________________________________
Policy Holder Name: ________________________________________
Policy ID #: _______________________ Group #: _______________
If no, please explain: _________________________________________
Telephone: ______________________ Date of Birth:_______________
If Yes and your application was rejected, explain reason for rejection:
Secondary Insurance: ________________________________________
Patient Clinical Information
Policy ID #: _______________________ Group #: _______________
Patient Diagnosis : __________________________________________
Telephone: ______________________ Date of Birth:_______________
ICD-9 Code: ______________________________________________
Route of Administration:  IV
 Subcutaneous
Site of Service: 
 Hospital Outpatient Clinic
 Hospital Inpatient.
Patient Financial Information
Policy Holder Name: ________________________________________
number: _________________________________________________
 No  Yes (Please explain): __________________________________
Physician Information
Physician Name: ___________________________________________
(To be completed for Patient Assistance Program applications -
Site Name: ________________________________________________
Please attach income documentation for each of the sources checked below.
We are unable to process your application without the required information.
Documentation can include the previous year’s Federal Tax Return, W2 Form,
Check Stubs (3 months), etc.)
Street Address: _____________________________________________
Current annual household income: $ _____________________________
Number of dependents within household (include applicant): __________
Source of Income:  Wages  Family  Public Assistance  SSI/SSDI
 Other (Please explain): _____________________________________
City: _______________________ State: _______ ZIP: _____________
Phone: _______________________ Best Time to Call: _____________
NPI #:____________________________________________________
Tax ID #:__________________________________________________
State License #: __________________Expiration Date:______________
Patient Declaration
Financial Statement: I certify that the information provided in this form is correct
and complete. If needed, Millennium Pharmaceuticals, Inc. (“the Company”) and the
Patient Assistance Program (“the Program”) may request and obtain information about
my or my family’s income to enroll me in the Program. I understand that I will need to
reapply to this Program every twelve months.
Permission for Sharing Personal Health Information:
the Program, my doctor may give a representative of the Program information about
my health. My insurer and employer may give the Program information about my
insurance. People who work for and with the Company may see my health and
insurance information and the information on this form, but they may use it only for
but if it is accidentally disclosed, federal privacy laws will not protect it.
my mind before one year has passed, I can call the Program’s toll-free phone number
and tell them that I have decided to leave the Program. I can also inform my doctor,
insurer, or employer in writing that I do not want them to give the Program any more
information. I know that this means I may no longer be able to receive assistance from
the Program. I also understand that the Company has the right to change or end the
Patient or Representative Signature: _______________________________________
(If signed by representative, explain authority to act for the patient)
Name:__________________________________ Date:_______________________
Takeda Oncology and Takeda are registered trademarks of Takeda Pharmaceutical Company Limited.
Other trademarks are the property of their respective owners.
City:_________________________State: ___________ZIP: _________
Provider Declaration
To the best of my knowledge, this patient does not have any drug coverage
(including private insurance, Medicare, Medicaid, county funded assistance, or
other public programs) that has not been declared on this form.
If a patient is approved for the Patient Assistance Program, no claim may be
made to any third party payer for payment of product provided under the Patient
Assistance Program. Product provided under the Patient Assistance Program must
only be used for the approved patient and may not be sold, traded or returned for
do not charge the patient for those professional services associated with this regimen
that are not covered by the patient’s health insurer.
Please indicate that you agree to these terms by signing below. Failure to comply
with these terms may mean you (and any patients you treat) will no longer be
eligible to participate in the VELCADE Reimbursement Assistance Program. Your
Physician Signature: _________________________________________________
Physician Name (Print): _________________________ Date:________________
Copyright © 2015, Millennium Pharmaceuticals, Inc.
All rights reserved.
Printed in the USA