1. Patient Co-payment Pictures
2. Guidelines For Self Pay Patients

Required Information to Complete an Application for Assistance:

Patient Demographic Information

The pharmacist may charge general patients the allowable additional fee but the fee cannot take the cost of the prescription above the general patient co-payment for the medicine. This fee does not count towards the Safety Net threshold.

• First & Last Name
• Address & Phone Number
• Gender, Ethnicity & Marital Status
• Veteran Status, Employment Status, Date of Birth
• Social Security Number or Alien Number
• Financial Information
• Number in Household

Annual Household Income

1. Perform the following steps for each Patient Copay at the time of payment: From the Accounts menu on the left, click on Patients. Search for and select the desired Patient from the database. The Patient form will open, at the top of which is a toolbar, as.
2. If “Pay Another Amount” was selected, patients in Group A could make a partial payment. However, for Group B, our engineers designed a smart workflow that offered a self-service payment plan tailored to our client’s business rules (i.e. Minimum monthly payment.
3. Financial & co-payment assistance for cancer patients including cancer-related costs and co-pays. Our professional oncology social workers can find additional resources.

Patient Co-payment Pictures

• Do you file a Tax Return for the most current year?
• Has your Annual Income changed significantly from last year?

Authorized Person

• Is anyone else authorized to speak with CPR on the Patient’s behalf?
• If yes, the following fields are required: First Name, Last Name, Relationship, Special Authorization, Phone
  Number

Insurance Information

• Primary Insurance Carrier Insurance & Plan Type Policy ID & Group Number Telephone Number
• Subscriber’s Name and Date of Birth
• Co-Pay or Coinsurance for medical services
• Co-Pay or Coinsurance for pharmacy benefits
• Do you have Medicare Part D?
• Does the patient have a Medicare Supplement? Do you have Secondary Insurance?
• Is Insurance coverage continuation under COBRA in effect?
• Does this plan cover prescription drugs at the pharmacy and provider office?

Treating Physician Information

• Physician Name Facility Name Physical Address
• Phone and Fax Number
• Office Contact Name and Email Address, if known

Medical Diagnosis

Guidelines For Self Pay Patients

• Primary Diagnosis
• Date of Diagnosis

Treatment Plan

• Confirmation you have a treatment plan and are currently in treatment, have been in treatment in the last 6 months or will begin treatment in the next 60 days.