GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM PRESCRIPTION VERIFICATION FORM (TO BE COMPLETED BY PHYSICIAN ONLY) NAME OF PATIENT _____________________________ DATE OF BIRTH ___________________ NAME OF GUARDIAN_____________________________ _____ HOME PHONE _____________________ WORK PHONE ____________________ IN CASE OF EMERGENCY CONTACT PARENTS /OR ____________________________PHONE _________________ FAMILY DOCTOR __________________ OFFICE PHONE ___________________ Medical Insurance Plan No.: ______________________________ ____ A. Please note any health problem, physical handicap, emotional difficulty, behavioral problem, or facts which may limit full participation in our Sate Pharmaceutical Assistant Program. ________________________________________________________________________ ________________________________________________________________________ B. Patient is subjected to allergies: YES (__) NO (__) Codeine____ Sulfa_____ Aspirin______ Other___________________ C. Patient is subject to: __ asthma __ ear ache __ fainting __ tonsillitis __ eye infection __ sensitive skin __ sinus trouble __ frequent colds __ nightmares __ bronchitis __ sleepwalking __ convulsions __ headache __ bed wetting __ kidney problem __ nosebleed __ high blood pressure __ motion sickness __ allergies (describe) D. Patient wears contact lenses (__) or glasses (___) Medical Conditions and Diagnosis: (Check all that apply) High Blood Pressure _____ Diabetes _____ Arthritis _____ Cancer _____ Heart Lung _____ Other ___________________________________________________ ___________________________________________________ E. To ensure that all patients comply with their medication regimen in a cost contained manner, please provide a list of the patient current list of medication prescribed by you and the indication of its use. Medication Strength (mg) SIG Directions Prescribing Doctor Doctor Phone # Pharmacy Company Date NOTE: THE SPAP PROVIDES MEDICATION ASSISTANCE TO SENIORS. TO ENSURE THAT WE PROVIDE ADEQUATE COVERAGE FOR OUR SENIORS, WE ENCOURAGE PHYSICIANS TO PRESCIBE GENERICS UNLESS BRAND IS ABSOLUTELY NECESSARY!!! GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM SPAP APPLICATION MEDICARE I.D HICN. # ______________________________ DATE_______________________ NAME ________________________________________________________________________________________ Last First Initial SOCIAL SECURITY #________________ DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ CITIZENSHIP STATUS: A. Alien__ B. U.S. Citizen__ C. Resident Alien (Green Card) ___ ETHNICITY: A. Black____ B. Caucasian _____ C. Hispanic _____ D. Other _____ MARTIAL STATUS: Married___ Single___ Divorced___ Widowed___ Separated ____ NAME OF SPOUSE / CONTACT PERSON: ___________________________________________ (H) _______________________ (W) ________________________ (CELL) __________________________ ADDRESS: _____________________________________________________________________________________ EMPLOYMENT STATUS: A. Unemployed ___ B. Part-time employment___ C. Retired____ D. Full-time employment___ E. Are you interested in Employment? Yes____ No _____ Name of Employer ____________________________________________________ Address ____________________________________________________________ Phone __________________ HEALTH INSURANCE & PRESCRIPTION DRUG COVERAGE INFDORMATION: PLEASE INDICATE CURRENT INSURANCE & PLAN. CIRCLE ALL THAT APPLY. MEDICARE PART A MEDICARE PART B MEDICARE PART D MEDICAID OTHER____________________ ____________________ IF OTHER INDICATED PLEASE SUBMIT A COPY OF YOUR CARD(S) WITH THIS APPLICATION Please list current doctors and date last seen. Doctor Date Last Visited _______________________ ______________ _______________________ ______________ _______________________ ______________ What is the state of your health? Fair ___ Good ___ Excellent ____ Average___ Poor___ Do you have any ailments? ________________________________________________________________________ Do you have difficulties taking care of yourself? Yes ___ No ___ If yes, what are those difficulties? __________________________________________________________________ ______________________________________________________________________________________________ Please list medications that you are currently taking? ______________________________________________ _________________________________________________________________________________________ What are your food/drug allergies? _______________________________________________________________ ___________________________________________________________________________________________ SERVICES RECEIVED/ NEEDED: Mental Health Services ___ Home Delivered Meals___ Homemaker Services___ Home Health Care ___ Income Maintenance ___ Adult Protective Services___ Housing ___ Educational (U. V .I.) ___ Medical Assistance ____ Social Security ___ Food Stamps ___ Other ___________________________________________________________ CERTIFICATION AND AUTHORIZATION I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE. I UNDERSTAND THAT IF I PROVIDE FALSE, FRAUDULENT OR MISLEADING INFORMATION, I FACE FINES AND PENALTIES UNDER VI LAW. I AUTHORIZE THE SOCIAL SECURITY ADMINISTRATION, BANKING INSTITUTIONS, PRIVATE INSURANCE COMPANIES, AND OTHERS TO RELEASE INFORMATION NECESSARY TO DETERMINE MY VI SPAT ELIGIBILITY. I AUTHORIZE THE VI SPAP TO RELEASE INFORMATION ABOUT ME., IF APPLICABLE, AS NECESSARY FOR RECEPT OF VI SPAP BENEFITS AND MEDICAREPRESCRIPTION BENEFITS AND OR THE ADMINISTRATION OF THE VI SPAP PROGRAM, AS PERMISSIBLE BY FEDERAL OF LOCAL LAW. I FURTHER AUTHORIZE MY HEALTH CARE PROVIDER TO RELEASE ALL MEDICAL RECORD PERTAINING TO PRESCRIPTION COVERED BY VISAP TO ASSURE THAT THE SERVICES PAID FOR BY VI SPAP WERE APPROPRIATE. APPLICANT SIGNATURE/MARK__________________________________ DATE___________________ AUTHORIZED REPRESENTATIVE/POWER OF ATTORNEY/CONSERVATOR CONTACT INFORMATION: IF THE APPLICANT IS UNABLE TO SIGN FOR THEMSELVES PLEASE ATTACH PROOF OF RELATIONSHIP AS THE AUTHORIZED REPRESENTATIVE, POWER OF ATTORNEY, OR CONSERVATOR. NAME: ____________________________________ RELATIONSHIP: _________________________________ ADDRESS: __________________________________________________________________________________ TELEPHONE: ______________________________ E-MAIL:_______________________________________ GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM INCOME INFORMATION Date___________________________ I.D. NUMBER__________________ NAME OF CLIENT _____________________________________________________ INCOME INFORMATION: Wages/Salary/ Tips $___________________________________ Profit from Self Employment $ ___________________________ Interest from Savings Accounts $ _________________________ Interest from Certificates of Deposits (CD’S) $ ______________ Other Interest Income and Dividends ______________________ Pair Market Rental $ ________________________________ Other In-kind Income $______________________________ _______________________________ _______________________________ Rental Income $ _______________________________ Unemployment Insurance $_____________________ Workmen’s Compensation $_____________________ Veteran’s Compensation $_____________________ Social Security $_____________________ Pensions, Annuities & Private Insurance $ ____________________________ ____________________________ ____________________________ ____________________________ TOTAL INCOME $ _________________________________ CIVIL RIGHTS CLAUSE: No person shall, on the grounds of race, color, sex or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under this program. Please be aware to recertify I certify that the information given is true and correct. Client’s Signature: ______________________________ Employee’s Signature____________________________ Director’s Signature _____________________________