Health Med Assist, Inc.
CONNECTING PRESCRIPTION USERS WITH FREE DRUG PROGRAMS

Pharmaceutical companies gave away more than $1.5 billion in free prescriptions to people meeting their guidelines last year, yet only a small fraction of those eligible ever apply. As a general rule, you will qualify if –

·           You have no prescription coverage or have exceeded your policy limits, AND

·           You are single and earn less than $1,500 per month, or married and as a couple earn less than $2,000 per month.

How Does the Program Work?

Simply fill out the attached Health Med Assist application form and mail it back to us at the address below, along with the required income documentation and application fee. Our computers complete the pharmaceutical company forms and forward them to your doctor to be signed and dropped in pre-stamped mailers to the drug companies for review.

Upon approval, your free medications (typically a 90-day supply) are generally sent to your physician, whose staff notifies you that the drugs are available for pick up. We follow up when it is time to renew your applications. Virtually all classes of prescriptions are available except generic drugs and controlled substances. If you qualify, your drugs arrive approximately 6-8 weeks after you apply.

Who is Health Med Assist?

Health Med Assist is a patient advocate organization founded in 1999 by a Doctor of Pharmacy with 15 years of experience working with pharmaceutical assistance programs. Our transactional computer system eliminates much of the confusion that has prevented most eligible people from applying for Patient Assistance Programs.

What Does This Service Cost?

Health Med Assist charges a one-time application fee of $25, regardless of the number of drugs you apply for, plus a file maintenance fee of $10 per prescription per month. If both a husband and wife apply, two application forms (and two $25 checks) are required. Last year our average client saved $250 per month in prescription costs – over $3,000 per year!

Do You Have Friends or Loved Ones Who Need Help Meeting Prescription Costs?

We’d be delighted to explain how our program operates. If they would like to participate, we’ll mail out a free application form. Have your friend call us at (801) 277-9769, or toll free at (800) 277-9769.

Administered by Health Med Assist

4659 South 2300 East, Suite 205, Salt Lake City, Utah 84117

Tel (801) 277-9769 / Fax (801) 274-3229 / Toll Free (877) 277-9769

hma@healthgroupnet.com / www.healthmedassist.com       


Application Form

Pharmaceutical companies require the following information to process your application for free drugs. Please call us if you need any assistance – (801) 277-9769 in Utah, or toll free (877) 277-9769.

Patient Name

 
Telephone

 

Date of Birth

 

Social Security number

 

Street Address

 

Email address / Fax (if any)

 

City, State, Zip

 

Alternate Contact Name

 

Total Monthly Income

 
Alternate Contact Telephone

 

Primary Insurance Co. Name

 
Is Alternate the Main Contact?

Yes ___ No ___

Secondary Ins. (if any)

 

Any Prescription Coverage?

Yes ___ No ___

Male __ Female __

Married __ Single __

Divorced __ Widowed __

File Tax Return? Yes__ No __

Weight  _____  Height _____

A Veteran? Yes __ No __

Legally disabled? Yes__No__

Childproof Caps? Yes_  No_

Referred by

NeedyMeds, Inc.

___ People in Your Household

Applied for Medicaid Yes_ No_

Please supply the following information about the doctors who prescribe medication for you.

Prescribing Doctor Name (1)

 

Prescribing Doctor Name (2)
 

Street Address

 

Street Address

 

City, State, Zip

 

City, State, Zip

 

Clinic Name & Specialty

 

Clinic Name & Specialty

 

Telephone

 

Telephone

 

Please complete the table below - the prescription name, the number of ‘mg,’ how you were directed to take the medication (“one or two tablets every four hours as needed”) and the prescribing doctor.

Medication Name

# mg

Directions

Doctor 1 or 2

1.

 

 

 

2.

 

 

 

3.

 

 

 

4.

 

 

 

5.

 

 

 

6.

 

 

 

7.

 

 

 

8.

 

 

 

9.

 

 

 

10.

 

 

 


If you need more space for any of the information provided above, please use the other side of this sheet.

Please list your medical conditions:                                                                                                                                           

Please list any medications to which you are allergic: ______________________________________________

NeedyMeds

Income & Expense Information

Patient Name: _________________________

Please fill out the following information so that we can write supplemental letters to the pharmaceutical companies describing your expenses and your income if the need arises.

Text Box: Please Attach Proof of Income Please attach copies of documents needed to verify each of your sources of income to the satisfaction of the drug companies to which the applications are submitted. ►Social Security Benefits Statement. The preferred document is a Social Security Benefits Statement for the current year. If you cannot locate this statement, just call the Social Security Administration toll free at 1-800-772-1213, then select options 1, 4, then 2 during the lengthy recording. The Statement is normally mailed to you within 2 weeks. A new statement will be needed every year. ►Pension Confirmation Letter. If you receive a pension, drug companies require a letter on the pension company stationery stating the amount of the payment, and that the amount does not change during the year. This letter can be obtained by calling the company paying the pension. A new letter will be needed every year. ►Paycheck Stubs or Bank Statements. If you work, please attach copies of the stubs from your last month’s paycheck(s). A new set of stubs will be needed periodically. If you receive Social Security or a pension, but cannot obtain a Social Security Benefits Statement or Pension Confirmation Letter, submit your last month’s Bank Statement. A new Bank Statement will be needed periodically. Please Attach Completed IRS Form 4506 If you do NOT file a tax return, please complete the checked items on the attached Form 4506. If you DO file a tax return, please submit pages 1-2 of last year’s return. Please Attach Your Check for $25 Health Med Assist, Inc. charges a one-time application fee of $25, which will be refunded to you if you don’t appear to be qualified for any free drugs. This covers the cost of preparing all your application forms. A monthly paperwork processing fee of $10 per prescription is also required for keeping your information current to ensure a reliable supply of prescriptions. You will be billed each month.                   

Monthly Household Expenses

Mortgage or rent

$

Cable TV

$

Loan payments

$

Credit card payments

$

Utilities & phone

$

Car & home insurance

$

Medical insurance

$

Prescriptions (household)

$

Groceries

$

Gasoline

$

Newspaper & magazines

$

Life insurance

$

Property Tax

$

Other

$
Total Monthly Expenses

$

Monthly Gross Household Income

Social Security

$

Pension

$

Investment income

$

Wages

$

Alimony & child support

$

Disability

$

Unemployment

$

Other

$
Total Income

$

Quarterly Income (if any)

$

Liquid Assets of Household

Savings account balance

$

CD value

$

Money market fund value

$

Stocks & Bonds

$

Other

$
Total Liquid Assets

$

NeedyMeds

Authorization for Release of Medical Information

 

Patient Name:

 

Birth Date:

 

Street Address:

 

Phone:

 

City, State, Zip:

 

SSN:

 

Health Care Providers:

 

Phone:

 

By my signature below, I hereby authorize the above-named health care providers to release the following information from my medical file to Health Med Assist, Inc., 4659 South 2300 East, Suite 203, SLC, UT 84117: all prescription information, my diagnosis and problem list, results of my last physical and last three progress notes. This authorization also pertains to testing for AIDS, drugs, alcohol, and mental health records. I acknowledge that data to be released may include material that is protected by Federal Regulations 42 CFR Part 2 and 45 CFR Parts 160 and 164.

Other Agreements

In consideration for the services provided by Health Med Assist, Inc. (“the Company”), I hereby agree to pay a one-time application fee of $25 for the purpose of determining my eligibility for financial assistance on my prescribed medications, and a monthly paperwork processing fee of $10 per prescription. If I fail to pay when due, I agree to pay all expenses of collection incurred by the Company or its assignee. I understand that a few pharmaceutical companies may charge an additional “stocking fee” of $5-10 to be paid if I pick up their drugs at my local pharmacy. 

I attest that I do not currently have any prescription insurance benefits either because I am uninsured or because I have exceed my coverage limits at the time of this application. For this purpose, a prescription discount card is not considered prescription coverage. I understand that if I fail to notify the Company of medication changes prescribed by my physician(s) I  may receive medications for which no current prescription exists and which may be potentially hazardous to my health.

I certify that the information I have provided to the Company, including without limitation the proof of household income I have supplied, is true and complete. I authorize any party to whom I have given documentary proof of my income and expenses, including without limitation a Social Security Benefits Statement, to provide copies thereof to the Company solely for the purpose of applying to pharmaceutical companies for grant drugs.

I understand that the Company acts only as a processing assistant to help me apply for free drugs offered by pharmaceutical companies; it does not manufacture drugs, prescribe drugs, recommend medication, or evaluate prescriptions. Accordingly, I waive any and all past and future claims I may have against the Company arising out of my participation in its drug program, and agree to indemnify the Company, its employees, and representatives, against any claims made by persons arising out of my participation. I assume all responsibility for notifying the Company of changes made to medication regimens.

I appoint the Company my attorney-in-fact for the limited purposes of signing in my behalf any communications or agreements with pharmaceutical companies, or other entities engaged by them to administer patient assistance programs, to which I may apply, and disclosing to such entities any of the medical information contained in the attached application form or proof of income documents submitted by me.

 

___________________________________                     ______________________________________
Date                                                                                              Signature of Patient

NeedyMeds