The EUFLEXXA Commitment Refund Form · 2020-02-21 · The EUFLEXXA Commitment Refund Form Offer...

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