GSK Patient Assistance Program

PO Box 220590, Charlotte, NC 28222-0590

Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET

GSK Patient Assistance Program Application Check List:

Call 1-866-728-4368 with any questions about how to complete this form

The GSK Patient Assistance Program provides certain GSK medicines at no cost to eligible applicants. Eligibility is
based on household income and insurance status. Residents of the United States, District of Columbia, and Puerto
Rico may be eligible for both Vaccine and Non-Vaccine Medicines. Please be aware, this program does not
constitute health insurance.

Complete all required sections of the application. An incomplete application will delay processing.
 All Applicants: Complete sections 1, 2, 3, 8 AND
• Vaccine Applicants: Complete sections 4 and 5.
• Non-Vaccine Applicants: Complete sections 6 and 7.

Fax or mail the following:

 Completed and signed application.
 Signed prescription. Signed original prescription(s) for GSK medication(s) written as medically appropriate.
Note: Faxed prescriptions will only be accepted as valid if faxed directly from a physician’s office and
accompanied by a fax cover sheet. All applications (vaccine and non-vaccine) must have a valid
prescription submitted in order for product to be shipped.
 Medicare Part D applicants must also send:
● Proof that they have spent $600 out-of-pocket on prescription medications.
Documentation includes all pages of the patient’s most recent Medicare Part D prescription drug plan
statement (Explanation of Benefits – EOB) indicating the patient has paid a total of $600 for
prescriptions in the current calendar year. If the statement is not available, please call the GSK PAP at
1-866-728-4368 for help to identify other sources of proof.
Note: The $600 expenditure can be co-pays, deductibles and direct costs for any prescription
medication. The prescription expenses must not include monthly premiums or expenses of family
members.
● A copy of their Medicare Part D prescription drug card. Please do not send original card(s).

Please keep a copy of the application and all documents for your record. Do not send original documents
as they will not be returned.

• All required sections of the application

need to be completed (see above).
• A valid prescription is required for all
applications.

APP-000002 Page 1 of 5
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET

Judith K. Todd
Patient Name: _________________________________ 12/25/1945
Patient ID: ___________________ DOB: __________________

Section 1: Applicant Information Required

Judith
Name (First):____________________________ Todd
(Last): ____________________________ K
(M.I.): ______ Gender: M  F 
✔

4551 Hannah Ford Rd Pegram Tn 37143

Mailing Address: _________________________________________ City: ___________________ State: _____ Zip: ____________
615 _____-_______
Primary Phone Number: (____) 662 1381 12 28 1945
Birth Date: _____/_____/________ 414 72 9377
Social Security Number: __________________
MM DD YYYY

If you would like to receive GSK patient assistance alerts, notifications and updates through email, please provide an email address.
Email: ______________________________________________________________________________________________________
2
Number of people, including applicant, who live in the household? _____ 2
Number of people dependent on household income? ______
2000 ____ or Gross Annual Income: ____________________________
Total Gross Monthly Income: _________________________________
Advair Diskus
GSK Medication(s) Requested: ________________________________________________________________________________
Drug Allergies Required: Do you have any known drug allergies? Yes  ✔ No 
SEE ATTACHED PAGE
If Yes, list any known drug allergies: ______________________________________________________________________________
___________________________________________________________________________________________________________
Health Conditions Required: Do you have any known health conditions? Yes 
✔ No 
SEE ATTACHED PAGE
If Yes, list any known health conditions: ____________________________________________________________________________
____________________________________________________________________________________________________________

Section 2: Prescription Coverage Required

1. Does the applicant have prescription drug coverage through a Health Insurance Marketplace
Plan/Exchange (also known as Affordable Care Act)? Yes  No 
✔

2. Is the applicant eligible for any state or federal (not including Medicare Part D) prescription drug
coverage plan such as Medicaid? Yes 
✔ No 
3. Does the applicant have any private prescription drug coverage (including employer sponsored
plans, private group plans, etc.)? This does not include Medicare Part D drug coverage.
Yes  No 
✔

Coverage gap
● If yes to question 3, please indicate why assistance is needed: __________________________________________________

4. Is the applicant enrolled in a Medicare Part D prescription drug plan? Yes  No 

● If not, check no and skip to question number 5.
st
● If yes, has the applicant spent $600 or more on prescription expenses since January 1 of the current calendar year?
 If yes, please provide the patient’s most recent Medicare Part D prescription drug plan statement (EOB) indicating the patient
paid a total of $600 for prescriptions in the current calendar year.
 If no, please wait until the applicant has spent $600 or more on prescription expenses to apply.

5. Is the applicant eligible for Puerto Rico’s Government Healthcare Program, Mi Salud? Yes  No 

APP-000002 Page 2 of 5
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET

Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________

Section 3: Authorized Individuals (optional)

For the patient: If you would like to give permission to GSK for other individuals (i.e. adult child, parent, friend) to conduct business on
your behalf, please print their names here. Please note: These individuals are in addition to a legal guardian or registered advocate who
may already be included on this application. NOTE: Please make sure everyone who should be able to call in on your behalf is
listed on the application, either as an authorized individual or provider/advocate. Otherwise, GSK Patient Assistance Program
will not be able to release information to anyone other than the applicant.

Name: _______________________ Phone Number: _______________________ Relationship to Patient: ____________________

Name: _______________________ Phone Number: _______________________ Relationship to Patient: ____________________

Name: _______________________ Phone Number: _______________________ Relationship to Patient: ____________________

Name: _______________________ Phone Number: _______________________ Relationship to Patient: ____________________

If you (the patient) or any of the above listed authorized individuals would like to receive GSK patient assistance alerts, notifications and
updates through email, please provide an email address below.
Email Address: _______________________________________________________________________________________________

VACCINE PATIENTS ONLY

Section 4: Shipping Address Required

Required Replenishment Prescriber Shipping Address

Prescriber Registration ID #:______________________________________
Prescriber must register for the Vaccines patient assistance program only. Enroll online at GSKPatientAssistanceProgramPortal.com. If
there are any questions regarding the registration process, please call 1-866-728-4368.
Prescriber Name: ___________________________________ SLN #: ___________________ Expiration Date: ________________

DEA Number: ________________________________ Prescriber Email address: ________________________________________

Clinic Name: _________________________________________________________________________________________________

Street Address: ___________________________________________ City: ___________________ State: ______ Zip: ___________

414 72
Phone Number: (____) _____-_______
9377
Fax Number: (____) _____-_______

Preferred Delivery Day:  Tuesday  Wednesday  Thursday  Friday

Section 5: Prescriber Information and Certification Required

My signature certifies that I am a licensed practitioner eligible under state law to prescribe, receive, and administer the requested
medication(s) listed on this program enrollment form, shipped from GSK Patient Assistance Program (GSK PAP). I attest that the vaccine
requested is indicated medically for the identified patient. I certify to the best of my knowledge, that the information on this application is
correct and complete. I attest that the product I receive is a replacement of a previously purchased GSK vaccine. I also understand that
eligibility under the program is subject to GSK’s discretion and GSK reserves the right to modify or terminate the GSK PAP at any time. I
represent that I have obtained all necessary authorizations, including a current and completed HIPAA Authorization Form, from my patient
to allow me to release information to GSK and its contracted third parties.

My signature confirms that the vaccine product will be provided at no cost to the patient listed on this form and I understand that I am not
eligible to seek reimbursement from any source for any medication provided by the GSK PAP. I understand that I will not receive
reimbursement from GSK for the administration of this vaccine and further agree that I will not seek reimbursement for administration of
the vaccine from any public payer.

Prescriber Signature: ______________________________________ Date: _______________________________________

(Original signature required. Stamped signature not accepted.)

APP-000002 Page 3 of 5
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET

Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________

NON-VACCINE PATIENTS ONLY

Section 6: Advocate Information (optional)

Advocate ID #:______________________________________ Email Address: ____________________________________________
Register at www.GSKPatientAssistanceProgramPortal.com or by calling 1-866-728-4368
Facility Name: __________________________ First Name: ___________________ Last Name:___________________ M.I.: _______
Street Address: ___________________________________________ City: ___________________ State: ______ Zip: ___________
Primary Phone Number: (____) _____-_______ Fax Number: (____) _____-_______

By my signature, I certify to the best of my knowledge, the information on this application is correct and complete. I have no knowledge of, nor do
I have any intent to, sell, barter or give this product to any person other than the Applicant for whom it has been prescribed. I have no knowledge,
the Applicant has no medical/prescription insurance benefits for the indicated pharmaceutical(s), including Medicaid or other public programs
other than as indicated, and the Applicant has insufficient financial resources to pay for the prescribed therapy.

Advocate Signature: ______________________________________________________ Date: _______________________

(Original signature required. Stamped signature not accepted)
If you would like to receive GSK patient assistance alerts, notifications and updates through email, please provide an email address.
Email: ______________________________________________________________________________________________________

Section 7: Shipping Address (complete only if different than mailing address in Section 1)

Addressee or Business Name:

_________________________________________________________________________________________________________
Street Address: ___________________________________________ City: ___________________ State: ______ Zip: _________
Phone Number: (____) _____-_______ Fax Number: (____) _____-_______

Specify addressee’s relationship to the applicant:  Self  Advocate (must complete Advocate Information in Section 6)
Prescriber  Other (specify relationship)
_____________________________

Refills Are Not Automatically Shipped. Please Visit Us Online Or Call Us To Request Your Refill.

APP-000002 Page 4 of 5
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET

Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________

Section 8: Patient Certification Required

By my signature I authorize GSK, as well as Lash Group and any other companies that GSK uses to administer the GSK Patient Assistance
Program (GSK PAP) (the “Program”) to do the following:

1) Use any information that I provide in my application for the purpose of helping me receive GSK products under the program or to administer
the Program.
2) Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the Program;
3) Contact my doctor, healthcare provider, or pharmacist about my application for the Program, and disclose to them information contained in
my application, in order to help me receive GSK products under the Program and ensure that program guidelines are being met;
4) Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive
under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to
administer the Program;
5) Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient
advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage or other funds, and disclose to them
information contained in my application or information about my prescribed medications and medical condition that has been provided by my
physician, healthcare provider, or pharmacist;
6) Disclose any information obtained from the sources listed above to third parties if required by law.
7) Authorize GSK PAP and its Administrators to obtain a consumer report on me. My consumer report, and the information derived from public
and other sources, will be used to estimate my income as part of the process to decide if I am eligible to receive free medication from GSK
PAP. Upon request, GSK PAP will provide me the name and address of the consumer reporting agency that provides the consumer report.
8) Request additional documents and information at any time, even if I am already enrolled, so that they can decide if the information on this
form is complete and true.

I understand that GSK does not charge a fee for participation in the Programs. If I have used a third party who charges a fee for help with my
enrollment form or refills of my medicine, this money is not paid to GSK. I understand this Authorization to Release and Disclose Medical
Information will remain in effect for as long as I participate in the Programs and for a period of 7 years after my participation in the Program ends. I
understand my healthcare providers will not condition my medication treatment on my agreement to sign this Authorization to Release and
Disclose Medical Information. I also understand that I have the right to revoke this authorization at any time by calling 1-866-728-4368, and
mailing a signed written statement of my revocation to the Program. Such a revocation would end my eligibility to participate in the Program.
Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been taken in
reliance on my authorization. I understand that once medical information about me has been disclosed in reliance upon this Authorization, the
information may no longer be protected by federal privacy laws and may be further disclosed. I certify that the product I receive from GSK PAP is
for my own use and will not be sold, bartered or given to any other person. I certify that the information provided in this application is complete and
accurate to the best of my knowledge and agree to notify GSK of any change in my insurance eligibility or financial status.

Patient or Legal Guardian Signature: __________________________________________ Date: _____________________

(Original signature required.)

Printed Name (if other than Applicant): _______________________________________________________________________

Relationship (if other than Applicant): ________________________________________________________________________

APP-000002 Page 5 of 5