3. PATIENT INFORMATION
First Name: Last Name: MI: Preferred Name:
Address: Apt/Unit #: City:
State: ZIP Code: Phone #: ( ) – Preferred Language:
Email: Date of Birth: / / SSN # (Last 4 digits):
Alternate Contact Name: Phone #: ( ) – Relationship:
REQUIRED
CONTACT AUTHORIZATION
I authorize Advancing Access to provide me with information on my benefits and other communications that contain
reference to the Advancing Access program or the ARx Patient Solutions Pharmacy through the following (select all
that apply):
NOTE:
If I do not select a contact preference,
I understand that Advancing Access will
provide program communications to me
by phone and/or through my healthcare
provider
Text message and data rates may apply.
You can opt out of such text messages at
any time by replying “STOP”
I authorize Advancing Access to leave a detailed message, including the name of my prescription, if I am unavailable
when they call.
Email Phone call Text message US mail
Yes No
4.INSURANCE INFORMATION
PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF INSURANCE CARD(S)
Patient is uninsured (ie, no health insurance through any public or private payer) — SEE OPTIONAL “PATIENT FINANCIAL INFORMATION” SECTION 5
Patient is insured (Please fill out all of the applicable insurance information below — Include copy [front & back] of all insurance cards, including medical and prescription.)
PRIMARY INSURANCE
Primary Insurance: Is this a Medicare Part D plan? Yes No
Plan Name: Insurance Phone #: ( ) –
Subscriber Name:
Policyholder Name: Policyholder Relationship to Patient:
Policy #: Group #: Rx Bin #: Rx PCN #:
Check this box if patient has secondary insurance coverage and include a copy [front and back] of insurance cards, if available.
REQUIRED
2.GILEAD MEDICATION PRESCRIBED
Product Name: If requesting DESCOVY
®
or TRUVADA
®
, please indicate for:
REQUIRED
Treatment PrEP/Prevention
1.REQUESTED PATIENT SUPPORT
CHECK ALL BOXES THAT APPLY
Benefits Investigation Co-pay Coupon Program Prior Authorization and Appeals Information
Patient Assistance Program (PAP) or Medication Assistance Program (MAP) Eligibility Screening
REQUIRED
THIS PAGE TO BE COMPLETED BY PATIENT OR PATIENT’S REPRESENTATIVE
PATIENT CONFIDENTIALITY: Patient confidentiality is of primary importance to us. All patient information will remain confidential. Information may be
provided to clinicians, social workers, or family members when required to complete the enrollment process and coordinate patient assistance, and to credit
bureaus to determine program eligibility with your consent within this Enrollment Form.
After submitting this form, a dedicated Advancing Access program specialist may reach
out to you to walk you through the next steps of the process and answer any questions.
PATIENT ENROLLMENT FORM
: 1-800-226-2056|: 1-800-216-6857
(Monday through Friday, 9 –8  EST)
Patient and Provider resources are
available at:
GileadAdvancingAccess.com
Page 1 of 5
Page 1 of 5
CLEAR FORM
5.PATIENT FINANCIAL INFORMATION
Current annual household income: $ _____________ (Documentation for all sources of income may be required)
Number of people in household supported by current annual income: 1  2 3 4 5  Other:
_________
REQUIRED ONLY IF APPLYING FOR THE PATIENT ASSISTANCE PROGRAM/
MEDICATION ASSISTANCE PROGRAM PAP/MAP
ADDITIONAL INSURANCE INFORMATION
Has the patient applied for the AIDS Drug Assistance Program (ADAP) or PrEP Drug Assistance Program? If Yes, date of application: ________________
What is the ADAP status of the patient? Not applied Pending Wait-listed Denied(include denial letter) Not eligible, reason: ___________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Is the patient eligible for Medicaid?
If No, state reason (if denied, include a copy of the denial letter): ___________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has the patient applied for Medicaid?
If Yes, date of application: __________________________
Is the patient eligible for Medicare?
If No, state reason (if denied, include a copy of the denial letter): ___________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has the patient applied for Medicare?
If Yes, date of application: __________________________
Is the patient eligible for VA benefits?
If Yes, has the patient tried to obtain the
medication through the VA?
Is the patient eligible for an insurance plan oered through a state insurance
marketplace (also known as an exchange)?
If No, state reason: ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has the patient applied for an insurance
plan oered through a state insurance
marketplace (also known as an exchange)?
If Yes, date of application: __________________________
YesNo
YesNo
YesNo
YesNo YesNo
YesNo
YesNo
YesNo
/ /
/ /
/ /
YesNo
SIGNATURE OF PATIENT or PATIENT’S AUTHORIZED REPRESENTATIVE UNDER FEDERAL OR STATE LAW (REQUIRED): DATE:
PATIENT REPRESENTATIVE’S NAME IF SIGNING FOR THE PATIENT: PATIENT REPRESENTATIVE’S RELATIONSHIP TO PATIENT: PHONE #:
/ /
( ) –
APPLICANT CONSENT AND DECLARATIONS
By signing below, I certify that all of the information provided in this application, including household income, is complete and accurate.
I understand that program assistance will terminate if Advancing Access becomes aware of any false or inaccurate information or if this medication is no longer prescribed
for me. I understand that I may only use the free product received through the PAP/MAP for my own use and personal consumption, and that I will not oer the product for
sale, resale, barter, or trade.
I understand that completing this application does not ensure that I will qualify for patient assistance. If I receive free product through the PAP/MAP, I certify that I will not
seek reimbursement or credit for this medication from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I will not seek to have
this medication, or any cost for items associated with it, counted as part of my out-of-pocket cost for prescription drugs. I understand that the PAP/MAP reserves the right to
modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice.
I authorize the PAP/MAP and its administrator to forward my prescription to a dispensing pharmacy on my behalf. Advancing Access may require me to submit proof of identity
and income documentation to verify my eligibility into the PAP/MAP (eg, identification card, tax return, W-2, last two pay stubs, etc). I authorize Gilead and its third-party
administrator to use the information provided on this form to obtain a personal credit report about me to verify the information on this form and determine my
eligibility for the PAP/MAP.
REQUIRED ONLY IF APPLYING FOR THE PAP/MAP
PATIENT CONSENT
By checking this box , I understand that my prescription will be shipped directly to the prescriber’s oce address listed on this form (Section 7). I authorize the prescriber
listed on this form, as my agent, to receive my prescription on my behalf. My prescriber, as my agent, will receive and then provide me with my prescription medication.
REQUIRED IF SHIPPING PRESCRIPTION DIRECTLY TO THE PRESCRIBER’S OFFICE/CLINIC
ADVANCING ACCESS
®
PATIENT ENROLLMENT FORM : 1-800-226-2056|: 1-800-216-6857
THIS PAGE TO BE COMPLETED BY PATIENT OR PATIENT’S REPRESENTATIVE
_______________________________________________________________________________________________ ______________________________________________________
/ /
PATIENT NAME: DATE OF BIRTH:
Page 2 of 5
Page 2 of 5
6.PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION
I understand that Gilead Sciences, Inc., and its agents, contractors, and other partners (“Gilead”) will need to obtain, review, use,
and disclose my personal and medical information before I can receive assistance through the Advancing Access program (the
“Program”) and the Patient Assistance Program/Medication Assistance Program (“PAP/MAP”). Additional information about how
Gilead may use my information can be found at https://www.gilead.com/privacy-statements.
Information to Be Disclosed: My personal information related to my enrollment or participation in the Program, which may include
personally identifiable information and Protected Health Information (“PHI”) as defined under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) as amended by the Health Information Technology for Economic and Clinical Health (“HITECH”)
Act (collectively Personal Information or “PI”):
• General information about me, including my name, birth date, and contact information
• Information about my medical condition, including information about my HIV-related status or treatment with this prescription
medication and related medical condition
• Information about my health benefits or health insurance coverage
• Financial information (as necessary), such as my income
• All information provided on this enrollment form and otherwise provided by me to the Program or PAP/MAP
Persons Authorized to Disclose and Use My Information: I authorize the following parties to disclose my PI to Gilead and its partners:
• My healthcare providers, including any pharmacy that fills my prescription medication. I understand that my pharmacy providers
may receive remuneration for disclosing my PI pursuant to this authorization
• Any health plans, including my health insurance company, or programs that provide me with healthcare benefits
I also authorize Gilead and its partners to redisclose my PI to the following parties:
• My healthcare providers, including the pharmacy that fills my prescription medication
• My health plans, including my health insurance company
• My authorized representative under federal or state law (if applicable)
Purposes for Which My Information May Be Used and Disclosed: My PI may be used and disclosed for the following purposes:
• Completing the enrollment process and verifying the information provided on my enrollment form, including confirming my
identity and my use or potential use of the medication prescribed by my healthcare provider
• Establishing my eligibility for benefits from my health plan or other programs
• Providing financial assistance and reimbursement support, if I am eligible, and providing other applicable support, including
information on third-party resources that may be able to assist me
• Communicating with my healthcare providers and coordinating my prescription and medication through a pharmacy or healthcare
provider’s oce
• Contacting me to evaluate the eectiveness of the Program and/or the PAP/MAP
• Gilead’s internal business purposes and audit and compliance purposes
• Confirming my receipt of the prescribed Gilead medication through the PAP/MAP based on my communication preferences above
• Deidentifying the information I provide, which means removing elements like my name and address so that I am no longer
reasonably identifiable
• Meeting Gilead’s legal requirements
REQUIRED
Please continue onto next page
>>>
ADVANCING ACCESS
®
PATIENT ENROLLMENT FORM : 1-800-226-2056|: 1-800-216-6857
THIS PAGE TO BE COMPLETED BY PATIENT OR PATIENT’S REPRESENTATIVE
_______________________________________________________________________________________________ ______________________________________________________
/ /
PATIENT NAME: DATE OF BIRTH:
Page 3 of 5
Page 3 of 5
6.PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION (CONTINUED)
Other Important Points:
• I understand that I may choose not to sign this authorization. If I refuse, my eligibility for health plan benefits or ability to obtain
treatment from my healthcare providers will not change, but I will not have access to the support oered by the Program and/or
the PAP/MAP
• Once I sign this Patient Authorization and my PI is transmitted to Gilead and its partners, I understand that state and federal
privacy laws may no longer protect or prohibit the redisclosure of the PI disclosed to Gilead and its partners by my healthcare
provider or others
• I understand that I am entitled to a copy of this signed authorization and that the authorization expires on the earlier of two (2)
years from the date it is signed by me or sooner if required under the laws of the state in which I live
• I understand that I may cancel this authorization at any time by notifying Gilead at 1-800-226-2056. If I cancel, Gilead will stop
using this authorization to obtain, use, or disclose my PI after the cancellation date, but the cancellation will not aect uses or
disclosures of any PI that have already been made pursuant to this authorization before the cancellation date
Marketing Communications Opt In (OPTIONAL): I would like to receive marketing and informational communications from Gilead related to my medical condition,
treatment, and/or my prescription medication, including oers, marketing and promotional information, and educational materials, via one or more of the communications
methods I agreed to above. I understand that opting in to the marketing and informational communications is not required as a condition of (i) eligibility for health plan
benefits or ability to obtain treatment from my healthcare providers, (ii) enrollment in the Program or PAP/MAP, or (iii) purchasing any goods or receiving a co-pay
or other support from Gilead. The marketing outreach program is separate from the PAP/MAP. NOTE: Advancing Access may communicate with me as necessary
to administer the Program, including PAP/MAP, even if I do not opt in to receive marketing and informational communications from Gilead.
By checking this box, I consent to receive marketing and informational communications from Gilead (as described above) to my phone number provided, including text
messages, prerecorded messages and phone calls, which may be sent via autodialer. Text and data rates may apply. I may opt out at any time by texting “STOP.”
SIGNATURE OF PATIENT or PATIENT’S AUTHORIZED REPRESENTATIVE UNDER FEDERAL OR STATE LAW (REQUIRED): DATE:
PATIENT REPRESENTATIVE’S NAME IF SIGNING FOR THE PATIENT: PATIENT REPRESENTATIVE’S RELATIONSHIP TO PATIENT: PHONE #:
/ /
( ) –
REQUIRED
ADVANCING ACCESS
®
PATIENT ENROLLMENT FORM : 1-800-226-2056|: 1-800-216-6857
THIS PAGE TO BE COMPLETED BY PATIENT OR PATIENT’S REPRESENTATIVE
_______________________________________________________________________________________________ ______________________________________________________
/ /
PATIENT NAME: DATE OF BIRTH:
Page 4 of 5
Page 4 of 5
FAX COMPLETED FORM TO
ADVANCING ACCESS AT 1-800-216-6857
7.PRESCRIBER INFORMATION
MUST BE COMPLETED BY A HEALTHCARE PROVIDER
Prescriber Name: Facility Name:
Address: City: State: ZIP Code:
Oce Contact: Phone #: ( ) – Fax #: ( ) –
NPI #: State License #: Tax ID #:
REQUIRED
8.DIAGNOSIS/MEDICAL INFORMATION
MUST BE COMPLETED BY A HEALTHCARE PROVIDER
Diagnosis (Please include ICD code[s]):
REQUIRED
HEALTHCARE PROVIDER CONSENT
I understand that completing this enrollment form does not guarantee that assistance will be provided to my patient. My patient has given consent for me to receive their Gilead medication on their
behalf. I will receive and secure my patient’s medication at my oce until it’s provided to my patient, when applicable. I will comply with and abide by my state practitioner dispensing laws for authorized
prescribers, when applicable. Any medications supplied by Gilead as a result of this enrollment form are for the use of the patient named on this form only and shall not be sold, traded, bartered,
transferred, returned for credit, or submitted to any third party (such as Medicare, Medicaid, or other benefit provider) for reimbursement. The medicine will be provided only to this eligible and enrolled
patient at no charge of any kind. The information provided on this enrollment form is subject to random audits and verification. Gilead may change or cancel this program at any time; Gilead also reserves
the right to terminate my patient’s enrollment at any time. If medicine is not provided to my patient within 30 days of receipt, medicine must be returned to the ARx Patient Solutions Pharmacy. Healthcare
facility may be subject to audits by Gilead and its third-party audit firm.
REQUIRED IF SHIPPING PRESCRIPTION DIRECTLY TO THE PRESCRIBER’S OFFICE/CLINIC
PRESCRIBER SIGNATURE (REQUIRED): DATE:
/ /
NO STAMP ALLOWED
10.PRESCRIBER CERTIFICATION
By signing this form, I certify that I am personally prescribing or furnishing Gilead medication for the patient identified in Section 3. I certify that this prescription medication
is medically necessary for the patient and that it will be used as directed. I certify that I will be supervising or coordinating the patient’s treatments, in accordance with law,
and verify that the information provided as part of my patient’s application for the Patient Assistance Program/Medication Assistance Program (“PAP/MAP”) is complete
and accurate to the best of my knowledge. I certify that I have not received and shall not seek reimbursement for any Gilead medication dispensed to the patient through
the PAP/MAP from any government program or third-party insurer. If applicable, I certify that medication provided to me by the PAP/MAP for the eligible patient identified
in Section 3 will be provided by me to such patient for his or her own use without charge. I certify that I will not otherwise use any such medication or prescribe, provide,
furnish, or dispense all or any portion thereof to any other person or patient. I will notify Gilead if all or any portion of the medication provided to me by the PAP/MAP for the
patient identified in Section 3 is not prescribed, provided, furnished, or dispensed to that patient, and I will ensure such medication is returned to Gilead or its designated
representative, by calling 1-800-226-2056 within 30 days. I certify that I will not sell, resell, oer for sale, trade, or barter medication provided to me under the PAP/MAP.
I consent that Gilead may perform an audit related to: 1) the applicant identified in Section 3, including but not limited to confirming patient identity and verifying medical
necessity; and 2) the dispensing of medication provided to the prescriber through the PAP/MAP, including confirming patient receipt of the prescribed Gilead medication
and the timely return of any medications received for, but not dispensed to, the patient identified in Section 3, if applicable.
If prescribing DESCOVY for PrEP® or TRUVADA for PrEP®, I certify that the applicant has been tested for HIV infection and found to be HIV negative, and regular HIV testing
will be conducted as part of the applicant’s care plan. As part of my applicant’s eligibility, I agree to periodically verify continued use of Gilead medication and resubmit
current prescriptions.
I certify that I have received the appropriate written authorization from the patient, in accordance with the Health Insurance Portability and Accountability Act of 1996,
applicable state health information privacy law(s), and any other applicable requirements, in order to release the patient’s personal and medical information to Gilead and
its agents and contractors for the purposes of assessing the patient’s insurance coverage and eligibility for participation in Advancing Access, conducting random audits to
verify the information provided on this enrollment form, and for other purposes as outlined in the Patient Authorization For Use and Disclosure of Personal Health Information
in Section 6. Gilead is authorized to contact me about the information provided on this form and as needed to facilitate my patient’s enrollment and participation in Advancing
Access. I understand that Gilead may, if authorized by the patient, contact the patient directly to verify Advancing Access eligibility and updates to insurance coverage, as well
as to confirm the receipt of Gilead medication through the PAP/MAP.
SPECIAL NOTE: New York prescribers, please submit prescription on an original NY State prescription blank. For all other states, if not faxed, prescription must be on state-specific blank if applicable for your state.
PRESCRIBER SIGNATURE (REQUIRED: DATE:
REQUIRED
/ /
NO STAMP ALLOWED
9. PRESCRIPTION INFORMATION
REQUIRED IF REQUESTING MAIL ORDER SHIPMENTS
PLEASE FILL OUT THE BELOW PRESCRIPTION FORM WHICH WILL BE SENT TO
THE PAP/MAP DISPENSING PHARMACY ONCE YOUR PATIENT IS APPROVED
Patient First Name: Last Name: Date of Birth: / /
Medication: Strength:
Quantity: 30 Directions for Use: Refills:
Delivery Options: Retail Pharmacy Pick Up Mail Order ShipmentsPick up initial supply at retail pharmacy (all subsequent fills via mail order)
Ship to: Patient Address (Section 3)Prescriber Oce Address Alternate Address
Alternate Ship to Address: City: State: ZIP Code:
ADVANCING ACCESS
®
PATIENT ENROLLMENT FORM : 1-800-226-2056|: 1-800-216-6857
THIS PAGE TO BE COMPLETED BY PRESCRIBER
_______________________________________________________________________________________________ ______________________________________________________
/ /
PATIENT NAME: DATE OF BIRTH:
Page 5 of 5
ADVANCING ACCESS, the ADVANCING ACCESS Logo, DESCOVY, DESCOVY
for PrEP, GILEAD, the GILEAD Logo, TRUVADA, and TRUVADA for PrEP are
trademarks of Gilead Sciences, Inc., or its related companies.
© 2022 Gilead Sciences, Inc. All rights reserved. US-ADMP-0208 12/22
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