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EZMeds Online Application

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First Name

Last Name

Gender

Email Address

Male

Female

The information in this box is required to determine your eligibility for the EZMeds USA Pharmacy Savings Plan
Did you file a tax return for 2008?	Household Income	Marital Status	Number of Children (Under 18)
Yes No

Do you have a medication insurance coverage? Yes No
(If Yes) Is your medication specifically exempt from coverage? Yes No

Birth Date (mm/dd/yyyy)	Primary Phone Number	Best Time to Call	Alternative Phone Number

Address		City	State	Zip Code

ADDITIONAL INFORMATION - Answering these questions completely and accurately will help speed up your application process.

Doctor's Information

Name

Phone

State

**If you have over 4 meds per doctor, our staff will confirm all medications.

Address

Current medication/s prescribed by this doctor:
Drug Name	Strength	Frequency

+ Add/Hide Doctor

Additional Contact Information
Does the patient have someone who helps with his/her medications (in-house nurse, relative, etc.) Yes No

Alternative Contact First Name	Alternative Contact Last Name	Relationship to Applicant	Contact Number

Address		City	State	Zip Code

Comments:

I understand:

-That not all medications I am taking may be available through the pharmaceutical companies tree drug programs.
-That pharmaceutical companies have certain criteria that must be met and that the pharmaceutical companies will make the final decision as to who qualifies for their 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.

- I will be required to provide proof of my income before any services will occur on my behalf.
- That once applications have been completed by, they will be mailed to my doctor for his/her signature. My doctor will then mail them back to EZMeds so they may be forwarded to the appropriate pharmaceutical company(s). EZMeds cannot be held responsible if applications are not returned by the doctor.
- That once the completed applications for the pharmaceutical companies PAPs (free drug programs) are returned to EZMeds 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 or EZMeds 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 EZMeds USA. 
- 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 my signature, I authorize EZMeds USA, LLC. 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 EZMeds USA, LLC. and its authorized agent(s) solely to administer the PAPs and those services provided only by EZMeds USA, LLC, but will not be used or disclosed for any other purposes, except as may be required by applicable law. I understand that neither EZMeds USA, LLC. nor my healthcare provider may be held responsible in the event I provide information deemed to be fraudulent.

Please include proof of income, latest tax return or Social Security income statement.

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EZMedsUSA is a Prescription Drug Assistance Program like those seen on Montel Williams and in other media coverage.
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