the euflexxa commitment refund form · 2020-02-21 · the euflexxa commitment refund form offer...
TRANSCRIPT
TheEUFLEXXACommitmentRefundForm Thisformisforreimbursementofupto$100foryourout-of-pocketcostsassociatedwithyourpurchaseofEUFLEXXA.Youmustmeetalltermsandconditionstobeeligibletoreceivearefundthroughthisprogram.FerringPharmaceuticalsinitssolediscretionreservestherighttoreviewyoureligibilitypriortoissuingyourrefund.TORECEIVEYOURREFUND:•Print,complete,andsubmitrefundform•AttachExplanationofBenefitsforeachinjectionfromyourinsurancecompany•Attachreceipt(s)reflectingpaymenttowardsyourcopayamountforEUFLEXXA•Faxto:TheEUFLEXXACommitmentat866-383-5392PleasefilloutandsubmitALLofthefollowinginformation:
1. FirstName:_____________________________________________________________________
2. LastName:_____________________________________________________________________
3. DateofBirth:___________________________________________________________________
4. Addressa. Street:__________________________________________________________________
__________________________________________________________________
b. City:____________________________________________________________________
c. Zip:____________________________________________________________________
5. PatientPhone:__________________________________________________________________
6. PhysicianName:________________________________________________________________
7. PhysicianAddress:_______________________________________________________________
8. PhysicianPhone:________________________________________________________________
9. InjectionDates(MM/DD/YYYY):
a. FirstInjection:___________________________________________________________
b. SecondInjection:_________________________________________________________
c. ThirdInjection:___________________________________________________________
TheEUFLEXXACommitmentRefundForm10. Totalout-of-pocketamount:$______________________________________________________
You’llreceivearefundbasedontheout-of-pocketamountyou’vepaid.Maximumrefundamountwillnotexceed$100.00.Therefundamountreceivedmayvaryfromthepriceenteredhereifyouhaveincorrectlyenteredtheamountpaid(asreflectedonyourExplanationofBenefits).Onlytheamountfortheinjectionadministrationand/orEUFLEXXAwillbereimbursed–officevisitcopayisineligibleforarefundthroughthisprogram.
11. PhysicianSignatureRequired:______________________________________________________
Bysigning,Icertifythat__________________________________(patient’sname)hasundergoneonlyonetreatmentregimenwithEUFLEXXA and the dates of the injections as listed above are accurate.
PatientAuthorization:Bysigningandsubmittingthisform,IamgivingmypermissionforthedisclosureanduseofmypersonalhealthinformationtoFerringPharmaceuticalsInc.("Ferring")anditsagentsforpurposes(i)ofdeterminingmyeligibilityfortherefundprogram;(ii)administeringmyrefund;and(iii)ofinternalbusinesspurposes,includingqualitycontrolandresearch.IunderstandthatFerringoritsagentsmaycommunicatewithmyhealthcareproviderandinsurerstodeterminemyprogrameligibility.IunderstandthatIamnotrequiredtosignthisformandprovidemyconsent,however,IcannottakepartintherefundprogramifIdonotdoso.IunderstandthatImaycancelmypermissionforFerringanditsagentstousemyhealthinformationatanytime,butifIdoso,Icannolongerparticipateintherefundprogram.Oncemycancellationrequestisprocessed,Ferringanditsagentswillnotbeabletousemyhealthinformationgoingforward,butmycancellationwillhavenoeffectoninformationthatIhavepreviouslyprovided.Iamgrantingmypermissionforuseofmypersonalhealthinformationforaperiodofthreeyearsfromthedateofthesignatureonthisform(unlessashorterperiodisprescribedbystatelaw).Iunderstandthat,unlessotherwiserestrictedbystatelaw,myhealthinformationreleasedunderthisformissubjecttore-disclosurebytheprogramandwillnolongerbeprotectedbyHIPAA.
Bysigningbelow,Icertifythat:(a) theinformationprovidedforthisrefundrequestiscompleteandaccurateandtheoutofpocketexpensessetforthabovewereactuallyincurred;(b) IhavemetalloftheeligibilityrequirementsfortheprogramandIamnotenrolledinanyfederalorstatehealthcareprogram,includingwithoutlimitationMedicare,Medicaid,DepartmentofVeteransAffairshealthcareprogram,TRICAREandanyfederalorstateemployeebenefitprogram;
PatientSignature:_______________________________________________________________
PatientName(Printed):__________________________________________________________
Date:_________________________________________________________________________
TheEUFLEXXACommitmentRefundForm
OfferTermsandConditions:• ThisofferisnotvalidforanyotherFerringPharmaceuticalsIncproduct.Fax-inonly.Nomail,phone,or
emailedrequestswillbehonored• FerringPharmaceuticalsisnotresponsibleforlost,late,damaged,misdirected,incompleteorillegible
submissions• Thevalueofthisrefundmaynotexceedtheamountofpatient’sresponsibility(copay)forthe
prescription.Maximumrefundamountis$100.• Offerlimitedtocash-payingorcommercialUSresidentswhoreceivedthree(3)injectionsofEUFLEXXA
within21daysasindicatedi.eoneinjectionaweekfor3weeksandareundergoingtheirfirstEUFLEXXAtreatmentregimen.
• Refundclaimsmustbereceivedbetween10and14weeksafterthelastinjection.AllclaimsmustbereceivedbyJanuary31,2020
• Limitonerefundpereligiblepatient• FerringPharmaceuticalsreservestherighttocancel,modify,orrescindtheprogramatanytime• Thepatientresponsibility(copay)fortheinjectionadministrationand/orEUFLEXXAmustbeisolatedon
theclaim.Officevisitsorotherancillarycostsincludedinpatient’sresponsibilityareexcludedfromrefundamount
• Thisofferisvoidwhereprohibitedorrestrictedbylaw.Offernotvalidforprescriptionsand/orservicesreimbursedinwholeorinpartbyanyfederalorstatehealthcareprogram,includingwithoutlimitationMedicare,Medicaid,DepartmentofVeteransAffairshealthcareprogram,TRICAREandanyfederalorstateemployeebenefitprogram
• Pleaseretaincopiesofthematerialsyousubmit.AllsubmissionsbecomethepropertyofaFerringPharmaceuticalscontractedthird-partyvendor
• Patientmustfullycompleteandfollowinstructionsasstatedontheclaimform• Tamperingwith,altering,orfalsifyingpaymentinformationconstitutesfraud• Pleaseallow4-6weeksfordeliveryofrefundcheck.RefundcheckwillbeissuedinUSdollars