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Get Novo Nordisk Patient Assistance Refill Form 2020

I further consent that Novo Nordisk may perform an on-site audit of Novo Nordisk Diabetes Patient Assistance Program PAP records related to the applicant named above on this application. I understand that I am not eligible to seek reimbursement for any medication dispensed by the Novo Nordisk Diabetes PAP from any government program or third party insurer and will not apply any Novo Nordisk Diabetes PAP medication towards the applicant s True-Out-Of-Pocket TrOOP costs. Novo Nordisk Patient Assistance Program Reorder Request Fax 866 441-4190 Phone 866 310-7549 Check this box if this request is for a new product or dose change Applicant Information Patient s Name Date of Birth Patient ID Number if available / Patient s State Licensed Health Care Practitioner Information State License Number Expiration Date NPI Number Practitioner s Name - Order Information Product Name Max Dose Per Day in units Sig Needle Information Needle Type Needle Gauge check one 30G 32G Health Care Practitioner Declaration* My signature certifies that I am a licensed health care practitioner eligible under state law to prescribe receive and dispense the requested medication s listed on the attached order shipped from Novo Nordisk and that I am not prohibited from participating in federally funded health care programs. I further certify that all information provided in the Licensed Health Care Practitioner Information section is correct. I agree that medication s provided to me by Novo Nordisk for the applicant named in the Applicant Information section will be provided by me to such eligible applicant for his or her own use without charge. I will not otherwise use any of such medications or prescribe provide or dispense all or any portion thereof for the use of any other person* I consent that Novo Nordisk may contact the applicant named in the Applicant Information section for verification of applicant status and receipt of the indicated medication s. I also understand that eligibility under the PAP is subject to Novo Nordisk s discretion and that Novo Nordisk reserves the right to modify or terminate the PAP at any time. Finally I certify that I receive no direct or indirect payments related to the PAP. Signature 2016 Novo Nordisk All rights reserved* USA15PCT01355 January 2016 Date. Novo Nordisk Patient Assistance Program Reorder Request Fax 866 441-4190 Phone 866 310-7549 Check this box if this request is for a new product or dose change Applicant Information Patient s Name Date of Birth Patient ID Number if available / Patient s State Licensed Health Care Practitioner Information State License Number Expiration Date NPI Number Practitioner s Name - Order Information Product Name Max Dose Per Day in units Sig Needle Information Needle Type Needle Gauge check one 30G 32G Health Care Practitioner Declaration* My signature certifies that I am a licensed health care practitioner eligible under state law to prescribe receive and dispense the requested medication s listed on the attached order shipped from Novo Nordisk and that I am not prohibited from participating in federally funded health care programs. I further certify that all information provided in the Licensed Health Care Practitioner Information section is correct..

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