A1065-1110
Patient Assistance Program
Form will be returned if information is incomplete. Incomplete forms will delay the application review process.
Gross Monthly Household Income: Please include your total GROSS MONTHLY HOUSEHOLD income. If that income comes from
salary/wages/dividends, social security, social security supplemental income, disability, unemployment compensation, pension/annuity,
alimony/child support, rental income or other (please specify), indicate the dollar amount. Attach most current W-2 forms or other proof of
income. If there is NO household income, please submit a letter with the application.
Signature and Date: You, or your legal guardian, must sign and date the application attesting that the information provided is both
complete and accurate.
All information contained in this application will only be used for
the purpose of evaluating the patient’s application for eligibility.
Patient (or Legal Guardian) Instructions
I hereby certify that the above information is correct and complete. I authorize UCB, Inc. and its agents to review the medical and financial
information provided. I also authorize UCB, Inc. to contact my prescribing physician, pharmacy or insurance company to discuss this
application, and any information about me that may be related to this application. I understand that this product is being provided free
of charge outside of Medicare, Medicaid, or any public or private third party. I certify that I will not submit any claims for reimbursement
or credit for product received to Medicare, Medicaid, or any third party payer. I understand UCB, Inc. has the right to revise, change, or
terminate the UCB Patient Assistance Program at any time.
______________________________________________________________
Da t e :
Pa t i e n t o r Le g a L gu a r D i a n Si g n a t u r e
Patient First Name:
Patient Last Name:
Address:
City: State: Zip Code:
Ph. #: Birth date:
Social Security #:
Medicare
ID #:
Salary/Wages/Dividends
Social Security
Disability
Unemployed Compensation
Gross Monthly Household Income of Applicant (Please attach most current documentation):
Pension/Annuity
Alimony/Child Support
Other: _________________
TOTAL/MONTH
$
$
$
$
$ $
$
$
.00 .00
.00 .00
.00 .00
.00 .00
Number of persons DEPENDENT upon primary income within family:
Are you currently enrolled in Medicare Part D? Yes No
Do you currently have prescription drug coverage Yes No
other than Medicare Part D?
If enrolled in Medicare Part D, please provide a copy of the front and
back of your Medicare Part D card.
Please indicate drug plan (PDP) name, address, & phone number.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
This section to be completed by Patient or Legal Guardian
- -
--
/ /
/ /
Alien Reg. #:
U.S. Resident Yes No Sex: Male Female Unknown
Attending Physician Instructions
Please complete all the required information below. In the space provided, indicate the patient’s diagnosis and/or diagnostic code(s). Gather
all information (including prescription and most current proof of income) and please ensure that all documents are signed and dated.
Mail the completed application to the UCB Patient Assistance Program at the address below.
I hereby certify that the above named person is my patient and the medications received for the UCB Patient Assistance Program are
only for the use of the patient named on this form. There will be no claim for reimbursement submitted concerning these medications
to Medicare, Medicaid, or any third party, nor returned for credit. I understand UCB, Inc. has the right to revise, change, or terminate the
UCB Patient Assistance Program at any time. I also certify that I am currently licensed with the appropriate state and federal authorities to
prescribe and dispense a Schedule V Controlled Substance.
______________________________________________________________
Da t e :
Ph y S i c i a n Si g n a t u r e / Pr o f e S S i o n a L De S i g n a t i o n
DEA #: State License #:
/ /
Expiration Date:
/ /
Ph. #:
This section to be completed by the Attending Physician
p
Vimpat 50mg Tablets Frequency* ____________
p
Vimpat 100mg Tablets Frequency* ____________
p
Vimpat 150mg Tablets Frequency* ____________
p
Vimpat 200mg Tablets Frequency* ____________
p
Vimpat 10 mg/mL Oral Solution Frequency* ____________
Please select one of the following drug strengths and provide frequency. Attach your prescription to this form.
CHECK ONE STRENGTH ONLY
Call 1-866-395-8366 if you have questions or need assistance.
Applications and prescriptions may be mailed or faxed to:
800-233-9141
Or
UCB Patient Assistance Program
PO Box 2198 Morrisville, PA 19067
UCB, Inc. reserves the right to change the provisions of this program at any time
Keppra
®
and Keppra XR
®
are trademarks of UCB Group of Companies
Vimpat
®
is a registered trademark under license from Harris FRC Corporation
- -
Physician’s First Name:
Physician’s Last Name:
Address:
City: State: Zip Code:
Diagnosis and/or Diagnostic Code(s): (Please select one.)
p
345.40 – Partial epilepsy with impairment of
consciousness; without intractable epilepsy
p 345.41 – Partial epilepsy with impairment of
consciousness; with intractable epilepsy
p 345.50 – Partial epilepsy without impairment of
consciousness; without intractable epilepsy
p 345.51 – Partial epilepsy without impairment
of consciousness; with intractable epilepsy
Please see attachment for FDA approved indications.
p
Keppra XR 500mg Tablets Frequency** ____________
p
Keppra XR 750mg Tablets Frequency** ____________
*Vimpat Maximum Daily Dosage = 400mg **Keppra XR Maximum daily dosage = 3000mg
Patient Assistance Program
