In order for you to become a 1 Easy Meds member, you must agree to and sign the following patient agreement. Below is the agreement for you to review. You may download, sign and fax it to us, when you are ready to submit your patient membership form.
Patient Agreement
I have completely filled out the membership enrollment form along with
this agreement. Please process it and coordinate all available medication
prescribed by my doctor with all applicable services available to me.
I understand:
that not all medications I am taking may be available throught the pharmaceutical
companies' free drug programs.
Those pharmaceutical companies have certain criteria that must be met and that the pharmaceutical companies will make the final decision as to who qualifies for the programs.
Below are GENERAL GUIDELINES established for the pharmaceutical companies' Patient Aid Programs:
Your gross yearly family income needs to be less than illustrated on the income chart. Total Gross Taxable Income includes: wages, social security, pension, disability, interest earnings, etc. (Excessive liquid assets may disqualify you from being approved for one or more medications).
You currently have no coverage (insurance or government program) that reimburses or pays for your prescription medications and you are experiencing a hardship in purchasing them.
That I will receive a telephone (qualification) call from 1EasyMeds to initiate qualifying me for the pharmaceutical companies' programs, and that when qualified, I will be required to provide proof of my income before any services will occur on my behalf.
That the enclosed non-refundable $35.00 enrollment fee is included with the application.
That once applications have been completed by 1EasyMeds, they will be mailed to you for you and your doctor signature. You will then mail them back to 1Easy Meds along with all other requested documentation so they may be forwarded to the appropriate pharmaceutical company(s). 1EasyMeds cannot be held responsible if applications are not returned by your doctor.
That once the completed applications for the pharmaceutical companies PAPs (free drug programs) are returned to 1EasyMeds it may take 6-8 weeks before I receive my first shipment of medications (generally a 90 day supply).
That the pharmaceutical company determines whether my medication is shipped to my physician, picked up at a local pharmacy, or shipped directly to my home. Clients of 1Easymeds cannot decide where medications are to be delivered.
That I am authorizing the alternate contact, if filled-in, on the Enrollment Form be approved to act on my behalf with regards to my account/records with 1EasyMeds.
I may cancel my service at any time, but no refund will be issued.
That, with regard to the pharmaceutical companies PAPs, the facilitator acts only as a processing assistant to help me apply for and complete applications necessary to receive free drugs offered by pharmaceutical companies; they do not manufacture drugs, prescribe drugs, dispense drugs, recommend medication, or evaluate prescriptions. I attest that the information provided in this application is complete and accurate. By signature, I authorize 1EasyMeds to request and obtain from my healthcare provider, insurance company, or pharmaceutical company/manufacturer or its contractors any of my medical records and information, financial and insurance records and information, and/or any other information necessary for the purpose of verifying the accuracy of the information provided in this application or related to my enrollment or participation in the various pharmaceutical patient assistance programs (PAPs). I understand that any such information obtained, as well as the information provided to me in this application, will be used by 1EasyMeds and its authorized agent(s) solely to administer the PAPs and those services provided only by 1EasyMeds, but will not be used or disclosed for any other purposes, except as may be held responsible in the event I understand that neither 1EasyMed nor my healthcare provider may be held responsible in the event I provide information deemed to be fraudulent.
Print Name:
Signature:
Date: