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2014 Program Reenrollment Agreements
Compliance: I understand that if I am accepted into programs offered by The Assistance Fund that financial assistance is being provided to help me afford my medications, my health insurance premiums and/or my basic need costs. Therefore, I agree to take my medications for which I receive financial assistance from The Assistance Fund and/or agree to timely pay my health insurance premiums and/or basic needs for which I receive financial assistance from The Assistance Fund. In the event that I do not comply with my medication regimen, pay for my health insurance premiums or pay for my basic needs as agreed, then I may be removed from participation in the programs offered by The Assistance Fund.
Certification and Acknowledgement: I agree that all of the information I have provided is truthful and accurate to the best of my knowledge. I understand that at any time during my enrollment in a program at The Assistance Fund that I may be contacted to request documentation of the Income Information and Household Size that I provided in my enrollment application for participation in such program(s). I understand that if The Assistance Fund requests evidence to support my Income Information or Household Size that I must respond to The Assistance Fund and submit the requested information within the designated timeframe provided. If I fail to submit the requested documentation within the designated timeframe, I may be terminated from the program.
I understand that I am free at any time to switch healthcare providers, practitioners, pharmacies, insurers or other healthcare suppliers without affecting my continued eligibility for assistance. I understand my application for assistance does not guarantee funding is or will be available. I understand that if I am approved for participation in a program, such financial assistance is provided for up to twelve months. Thereafter I must reapply for assistance each twelve months. Assistance in any year is always subject to the availability of funds and there is no guarantee such funds will be available.
Provision of Assistance: I acknowledge that The Assistance Fund provides financial assistance to individuals who qualify for participation pursuant to the rules established by The Assistance Fund. I further agree that if approved for financial assistance, my participation requires that I meet the program rules throughout the period of time that I receive assistance from The Assistance Fund.
Change in Insurance, Household Income/Household Size, or Other Information Provided in this Application: I agree that at any time that I am receiving assistance from The Assistance Fund if my insurance benefit changes, if I am no longer in need of assistance, in need of less assistance, or my household income or household size changes, I will immediately notify The Assistance Fund with such change. Changes may impact my participation in The Assistance Fund program(s) including a reduction in the amount of assistance provided or a termination of assistance entirely. All provisions of assistance are based upon the program rules established by The Assistance Fund and not all applicants are eligible for participation.
Furthermore, if I begin receiving government benefits and any portion of the benefits are for retroactive financial assistance, I am responsible for reimbursing The Assistance Fund for the same amount of retroactive assistance that I received under this program.
Waiver and Release of Liability: I understand that if I am enrolled in The Assistance Fund’s health insurance premium assistance program that, at the option of The Assistance Fund, funds may be paid directly to my insurance provider or to me as reimbursement for my payment to my insurance provider. I understand that the amount of assistance that I receive may only partially cover my insurance premiums. If the assistance only partially covers my insurance premiums, I understand that I have the responsibility to pay the balance of such premiums in order to fulfill my financial obligation with my insurer. I understand that a policy of insurance that is underwritten to cover me is my responsibility and that I retain the responsibility to ensure that the related insurance premiums are paid in accordance with the insurance contract terms and conditions. I hereby release The Assistance Fund from liability and forever waive my right to make a claim against The Assistance Fund for the cancellation of, non-renewal of, or denial of insurance (or any such application of insurance). I agree that it is my obligation to contact The Assistance Fund if I receive a notice of cancellation, non-renewal, or denial of insurance as such information may impact my ability to receive assistance from The Assistance Fund for such program.
Patient Authorization to use or release Protected Health Information: I authorize the use and disclosure of my individually identifiable health information (“Protected Health Information”) by The Assistance Fund, Inc, a non-profit organization, to process my application for program participation, if I am determined eligible and funds are available - to enroll me in a program(s), and to use and disclose my Protected Health Information to investigate my eligibility for assistance with other assistance programs, where applicable. I authorize my health care provider and insurance benefit provider (including my insurance benefit providers’ administrator – if any) to disclose to The Assistance Fund, Inc. my health information (orally or in writing) for the purposes herein. I also authorize The Assistance Fund and its third party contractor to use my Protected Health Information for the purpose of analyzing and evaluating The Assistance Fund’s programs to determine trends in insurance reimbursement, patient therapy compliance and other related statistics related to The Assistance Fund programs. De-identified data may be used as permitted by law. I understand that once my Protected Health Information is released pursuant to this authorization that it may be subject to re-disclosure. I may withdraw this authorization at any time by mailing or faxing a letter of revocation to The Assistance Fund at the address listed herein below; provided that such revocation will not have an effect on any actions taken by The Assistance Fund prior to The Assistance Fund’s receipt of my revocation of Authorization. If I revoke this authorization, I will no longer be eligible to receive assistance through The Assistance Fund’s Programs. This authorization expires annually. I understand that I may request an accounting of disclosures of my Protected Health Information by The Assistance Fund if I request it in writing and send it to The Assistance Fund, Inc. 4700 Millenia Boulevard, Suite 310, Orlando, FL 32839.