Name:Street Address:City: State: Zip: Date of Birth: Gender: Daytime Telephone:Evening Telephone:Best Time to Call: Email:
(No stamps. Please fax patient’s chart.)
PRESCRIBER INFORMATION
Physician Name: Office/Institution: Specialty: Street Address: City: State: Zip:
Office Contact: Telephone: Fax: Best Time to Call: Email: State License #: NPI #:
Secondary Insurer:Telephone:Subscriber Name:Date of Birth: ID#: Group #:
Prescription Drug Insurer: Card/Bin: Telephone:
INSURANCE INFORMATIONPrimary Insurer: Telephone: Subscriber Name: Date of Birth: ID#: Group #:
(Please fax front and back of patient’s insurance cards.)
Current Therapy:
Dose:Frequency: 2 weeks 3 weeks 4 weeks
Sandostatin® LAR Sandostatin® IR Somatuline® LAR Other:
Primary Language: Alternative Contact Name: Alternative Contact Telephone: Allergies: Comorbidities: Current Medications:
PRESCRIPTION (Check all that apply.)
XERMELO 250 mg TID, 28-day Supply Refills:
PRESCRIBER AUTHORIZATIONI authorize Lexicon Pharmaceuticals, Inc. as my designated agent and on behalf of my patient to (1) furnish any information on this form to the insurer of the above-named patient and (2) forward the above prescription, by fax or other mode of delivery.
Prescriber Signature: Date: (No stamps)
3 months 6 months 12 months
PRESCRIPTION FORM
Questions? Call LexCares at 1-844-Xermelo (937-6356)
PATIENT INFORMATIONPatient Name:
LEXCARES PATIENT SUPPORT PROGRAM DESCRIPTION AND PRIVACY NOTICELexCares is a patient support and coordination of care program sponsored by Lexicon Pharmaceuticals, Inc. In order for you to participate, Lexicon Pharmaceuticals, Inc., its affiliates, and agents (collectively “Lexicon”) will use and disclose your personal information, including your health information, collected on the enrollment form on page 1 and through participation in LexCares for the following purposes: 1) to enroll you in and provide you with LexCares and related support services, including benefits verification, financial assistance support, program onboarding, and medication dispensing; 2) nurse/patient education and support to contact you or your alternate contact (if listed) with: (a) informational and educational therapy materials related to your disease, relevant patient programs, and the use of your prescribed Lexicon products; and, (b) if you have checked the “Marketing Consent” box below, marketing materials related to Lexicon’s products, clinical trial and research opportunities, and other services; 3) to perform research and data analytics to develop and evaluate products, services, materials, and treatments. Lexicon may combine the information it receives about you with information from other sources. However, Lexicon will not sell or rent any information that can identify you to third parties for their own purposes or otherwise use or disclose any information that can identify you for any purpose not authorized above. If you have questions about this Privacy Notice, want to update your information, terminate your LexCares enrollment, or opt-out of Lexicon marketing, please call 1-844-XERMELO (937-6356).
MARKETING CONSENT I would like to receive communications related to Lexicon Pharmaceuticals’ products, clinical trial and research opportunities, and other services.
I would like to enroll in the patient support services and nursing support. Please contact me via Email Phone
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Date of Birth:
PATIENT CONSENT FORM
HIPAA AUTHORIZATIONI hereby authorize my healthcare providers and my health insurance carriers to disclose my personally identifiable health information, including my medical diagnosis, condition, and treatment (including prescription information); my health insurance; and my name, address, and telephone number to Lexicon Pharmaceuticals, Inc., and their agents and representatives, including third parties authorized by Lexicon to support LexCares within the scope in order to dispense XERMELO for the following purposes: 1) to contact my healthcare providers to collect, enter, and maintain my health information in a database and to provide information related to my treatment; 2) to contact my insurers as needed to verify my insurance coverage, review reimbursement issues, and assist with the processing of claims; 3) to contact me to receive educational and therapy support services designed for people taking XERMELO; 4) to evaluate the LexCares program, including analyzing and aggregating data to conduct analyses related to the programLexicon agrees to protect my health information by using and disclosing my information only for the reasons listed above. I understand that federal privacy laws may no longer protect my health information after its disclosure to Lexicon and that it may be subject to redisclosure. I understand that I may revoke (withdraw) this Authorization at any time by faxing a signed, written request to LexCares at 1-855-215-5318. LexCares will notify my healthcare provider and insurers of my revocation, who may therefore no longer disclose my health information to Lexicon once they have received and processed that notice. However, revoking this Authorization will not affect Lexicon’s ability to use and disclose my health information that has already been received to the extent permitted under applicable law. If I revoke this Authorization, I will no longer be able to receive LexCares services. However, the revocation of this Authorization will not affect my ability to get treatment from my healthcare providers or to seek payment or eligibility for benefits from my health plan. This Authorization will be in effect for five (5) years from the date I sign this document.
Patient Address:
If signed by representative, select the nature of the relationship with the patient:
Spouse Legal Guardian Representative per Power of Attorney Personal Representative
Name of Patient
Name of Representative (if needed)
Representative Address
Signature
Signature
Home Phone Number
Date
Date
Mobile Phone Number
Questions? Call LexCares at 1-844-Xermelo (937-6356)
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PLEASE BE SURE THE APPLICANT SIGNS AND DATES IN EACH PLACE INDICATED ON THIS FORM. ENROLLMENT CANNOT BE PROCESSED WITHOUT THE APPLICANT’S SIGNATURES.
Lexicon Pharmaceuticals, Inc., cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payer, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. For additional information, customers should consult with their payers for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record.
FINANCIAL INFORMATION (FOR PAP APPLICATION ONLY)*
Annual Household Income: $
Number of Household Members Dependent on Income
(include applicant): *Income documentation will be required in order to assess program eligibility (ie, written patient attestation, 1040 tax return, SSA-1099, W-2 form).
Source of Income: Job Family Public Assistance
SSI/SSDI Other (Please explain):
PRESCRIBER DECLARATIONI verify that the above information is complete and accurate to the best of my knowledge and that I have prescribed XERMELO based on my professional judgment of medical necessity. I authorize Lexicon Pharmaceuticals, Inc., and its affiliated companies or subcontractors to forward this prescription to a dispensing pharmacy on behalf of myself and my patient. I appoint the Patient Access Program (PAP) solely to convey on my behalf to the pharmacy chosen by or for the above-named patient, the prescription described herein. I authorize the PAP to perform a preliminary assessment of insurance verification for the above-named patient, and I further authorize and request that the PAP provide to me any and all information necessary for completing a Letter of Medical Necessity, as may be required as a result of such insurance verification assessment.
Prescriber Signature: Date: (No stamps)
PATIENT INFORMATIONPatient Name: Date of Birth:
PATIENT ACKNOWLEDGMENT (FOR PAP APPLICATION ONLY)
I understand that completing this form does not ensure that I will qualify for the Lexicon PAP. I understand that I must meet certain financial criteria in order to be eligible for the PAP. I hereby certify that the financial information provided in or in connection with this form is true, complete, and accurate and understand that Lexicon may pursue any and all legal remedies in the event such information is false, incomplete, or inaccurate. I agree to notify and shall be responsible for notifying the program administrator for the PAP if I obtain coverage through another source or if my financial situation changes. I understand that Lexicon reserves the right at any time and without notice to me to modify and/or discontinue any or all of the PAP, including modification of eligibility criteria and immediate termination of assistance provided by the PAP. I understand that I may decline to sign this form and decline being considered for the PAP.
