Novartis Patient Assistance Form – Fill Out and Use

Patient Section

Enrollment Application for the Novartis Patient Assistance Foundation, Inc.

PATIENT INSURANCE INFORMATION: Please include a copy of the front and back of your Prescription Card and Insurance Card

send my information to other programs that might help me pay for my medicines; ask me for nancial, insu rance and/or medical information and share my information as required or permitted by law. I give permission to the Foundation to use information on this Application and any other information I give to the Foundation for these same reasons. I also give the Foundation permission to share my Health Information and other information with people and companies that work with the Foundation; government agencies, including the Centers for Medicare and Medicaid Services; insurance companies, including Medicare Part D plans; my doctor(s) and other people, or institutions who are involved in my healthcare, such as pharmacies and hospitals; other organizations that might help me pay for my medication. I promise that any information, including nancial and insurance infor mation that I provide to the Foundation are complete and true and unless I have said something dieren t in this application, I have no drug insurance coverage, which includes Medicaid, Medicare or any public or private assistance programs or any other form of insurance. If my income or health coverage changes, I will call the PAP at 1-800-277-2254. I know that the Foundation may change or end the PAP at any time. I know that if I do not sign this form, I will not be able to participate in the PAP, but this will not aect my ability to get medi cal care, seek payment for this care or aect my enro llment or eligibility for insurance. I know that I can cancel this permission at any time by calling the PAP at 1-800-277-2254. If I do, then I will not be able to stay in the PAP. I understand I have the right to receive a copy of this form.

Patient or Legal Guardian Signature: ____________________________________________________________ Date: ________________________

Prescription Section

Enrollment Application for the Novartis Patient Assistance Foundation, Inc.

P.O. Box 66978, St Louis, MO 63166-6978 Phone: 1-800-277-2254

Fax: 1-855-817-2711 Web: www.npcpapportal.com

HEALTH CARE PROFESSIONAL (HCP) INFORMATION: To be completed by the HCP.

Read & Sign HCP Authorization

My signature below certies that the person listed above is my patient for whom I have prescribed the drug identied above. For the purposes of transmitting this prescription, I authorize Novartis Pharmaceuticals Corporation, and its af- liates, business partners, and agents, to forward as my agent for these limited purposes, this prescription electronical- ly, by facsimile, or by mail to a dispensing pharmacy chosen by the above-named patient. I certify that any medications received from Novartis (as dened above) in connect ion with this application will be used only for the patient named on this form. These medications will not be oered for sale, trade, or barter. Additionally, no claim for reimbursement will be submitted concerning these medications to Medicare, Medicaid, or any third party, nor will any medications be returned for credit. I acknowledge that I have assisted the patient in enrolling in the Novartis PAP exclusively for purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort. I also agree that Novartis has the right to contact the patient directly to conrm receipt of medicati ons, and I under- stand that Novartis may revise, change, or terminate this program at any time. Finally, to the best of my knowledge, the patient listed above meets Novartis’ eligibility criteria for the PAP.

Prescriber Signature: _________________________________________________________ Date:_____________________