ADVOCATES MUST CALL WITH A COMPLETED AND SIGNED FORM TO ENROLL

EACH PATIENT. DO NOT MAIL UNTIL DIRECTED.

GSK Product ICD-9 Code for Primary
Requested: Diagnosis:
PO Box 29038 • Phoenix, AZ 1.Wellbutrin SR
85038-9038 150mg
1-866-PATIENT(728-4368) 2.
www.BridgesToAccess.com PATIENT ID #898052431
SECTION 1 - PATIENT INFORMATION
Patient Name
Mary (Last):G (M.I.): Holt
(First):
Street Address:11 E Bell Road Apt# 104
ZIP
City: Phoenix State: AZ 85022 Phone #:
Code:
Drug Shipping Address (if different from above) C/O or Business Name: 11 E Bell
Road
11 E Bell Rd. Apt#
Street Address: City: Phoenix State: AZ
104
Phone Email
ZIP Code: 85022 etruelia50@cox.net
#: Address:
Social Security #: (Ex:XXX-XX- Birth
(MM/DD/YYYY)Gender: U.S. Resident
XXXX) Date:
M YES NO
239-88-0183 12/08/1950 F
Legally Disabled: YES NO Veteran: Race (Optional):
If yes, has patient been legally disabled more than two YES NO
years? YES NO
HOUSEHOLD SIZE & INCOME: List gross monthly income by income type for all
people who contribute to or are dependent on patient’s household income.
(Include number of people, including patient, who
HOUSEHOLD SIZE: 1 contribute to or are dependent on patient’s
household income.)
Social Security
Salary/Wages: Veterans Benefits:
Disability:
Unemployment:
Social Security Retirement: Pension/Retirement:
240.00 /week
Alimony/Child
Supplemental Security Income: Other:
Support:
TOTAL MONTHLY
INCOME $: 1196.00
INSURANCE INFORMATION: Indicate if patient has prescription drug benefits
through any insurer/payer/program and why the prescribed GSK product is not covered.
Medicare – Is the patient eligible for Medicare? YES NO
If yes, has the patient enrolled in any Medicare plan that includes Part D drug
coverage? YES NO
Does patient have prescription If “Y”, circle the appropriate letter for each insurer
drug benefits through any of the to indicate why the GSK product is not covered. (A
following insurers/ = Capitation limit; B = GSK product not on
payers/programs? (Y = Yes, N = formulary; C = Plan covers generic drugs only; O =
No, P = Pending or wait listed) Other - list reason)
Y N P
Medicaid A B C O:
 Y N P
Private Insurance A B C O:
AIDS Drug Assistance Y N P
A B C O:
Program
State Children’s Y N P
A B C O:
Insurance Program
Other State Drug Y N P
A B C O:
Assistance Program
Veterans Affairs Drug Y N P
A B C O:
Benefits
Y N P
Other - List Name: A B C O:
SECTION 2 - PRESCRIBER INFORMATION
Name (First): Houshang (Last) Aminian (M.I.):
Street Address: 11020 N Tatum Blvd. City: Phoenix
State: AZ ZIP Code: 85028 Phone #: Fax #:
DEA #: AA9273094 Email Address:
SECTION 3 - ADVOCATE INFORMATION
Name (First): Malie (Last) Malihi (M.I.):
Facility Name: Street Address: 11020 N Tatum Blvd
City: Phoenix State: AZ ZIP Code: 85028
Phone #: Fax #: Email Address:
SECTION 4 - SIGNATURES
Patient (or authorized representative), prescriber, and advocate must read and sign the
Certification and Consent to Release and Disclose Medical Information. PATIENT
SIGNATURE IS REQUIRED PRIOR TO
PHONE ENROLLMENT.
ADVOCATE: FOR YOUR PATIENT TO OBTAIN DRUG IMMEDIATELY,
COMPLETE THE PATIENT VOUCHER BELOW AND GIVE IT TO PATIENT
AFTER THE ENROLLMENT CALL.
GSKCS 051345D1 12/05 ©GlaxoSmithKline. All Rights Reserved.

PATIENT VOUCHER
Mary Holt
Patient Name:
G
1-866-728-4368
Malie
www.BridgesToAccess.com Advocate Name:
Malihi
Advocate Phone
Number:
This Patient Voucher serves two purposes: [1] it is PATIENT ID#:898052431
your program identification, and [2] it will help your
pharmacy process your prescription claim correctly. PHARMACY PROCESSING
INFORMATION
HOW TO FILL YOUR INITIAL PRESCRIPTION Processor - McK
THROUGH BRIDGES TO ACCESS:
RxBIN - 610500
After your advocate successfully enrolls you by RxGRP - H1160001
phone, take this voucher and your GSK
prescription(s) to a local retail pharmacy. Pharmacy Questions - Call 1-
You may obtain up to a 60-day supply per drug 866-728-4368
for a minimum co-pay per fill. between 8:00am - 8:00pm
If necessary, refills for most medicines are Eastern Time
available through our mail order pharmacy. Your
advocate can tell you how to obtain refills.
 Do not attempt to obtain refills at your local
pharmacy after 60 days unless directed to by your
advocate.
Contact your advocate if you have any questions.
THIS VOUCHER BECOMES VALID FOR USE AT A RETAIL
PHARMACY AFTER PHONE ENROLLMENT IS COMPLETED.

Patient Health and Allergy Information

To help us serve your patient, please complete the requested information below
DO NOT send this form until your patient has been enrolled into Bridges to
Access and or Commitment to Access
Please return this form along with the patient enrollment form and or any
additional required documentation
Please attach required prescription(s) for your patient Patient Information
(Required)

Patient Information (Required)

Patient ID Number: 898052431
Patient Name: Mary Holt
Patient Date of Birth: 12/08/1950
All prescriptions come with a safety cap. If you would like us to include a snap-on
cap, please check here.

Allergy and Health Condition Information

Place an “X” in the box next to each allergic or health condition for the patient

For Pharmacy Use Only Allergic Conditions "X"

32 Codeine
87 Sulfa
70 Penicillin
93 Tetracycline
00 No known allergies
00 Other (List)
00 Unknown
For Pharmacy Use Only Health Conditions “X”
200 Diabetes X
300 Hypertension X
400 Heart Disease
500 Glaucoma
600 Stomach Disorders X
700 Thyroid Disease X
800 Arthritis
000 No known health conditions
000 Other (List)
00 Unknown
Patient ID #:898052431
Patient Authorization to Release and Disclose Medical Information
By my signature I authorize GlaxoSmithKline, as well as McKesson Specialty Arizona Inc. (MSAZ) and
any other companies that GlaxoSmithKline uses to administer Bridges to Access (the “Program”), to do
the following:
1) Use any information that I provide in my application for the Program for the purpose of helping me
receive GlaxoSmithKline 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
GlaxoSmithKline 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. By signing below, I also authorize my insurer, doctor, healthcare provider, or pharmacist
to release information about my prescribed medications and medical condition that is requested by
GlaxoSmithKline, MHSA or any company that GlaxoSmithKline uses to run the Program.
5) Contact my insurer, other potential funding sources, 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 Program 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.
I understand that this Authorization to Release and Disclose Medical Information will remain in effect
for as long as I participate in the Program and for a period of 3 years after my participation in the
Program ends.
I understand that my healthcare providers will not condition my medical 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 understand that GlaxoSmithKline does not charge a fee for participation in this Program. There is a co-
payment for each prescription filled at a retail pharmacy. If my advocate charges a fee for enrollment or
refills of my medicine, this money is not paid to GlaxoSmithKline.
I certify that I am not enrolled in any Medicare plan that includes Part D drug coverage. Furthermore, I
certify that the information provided in this application is complete and accurate to the best of my
knowledge and agree to notify GlaxoSmithKline of any change in my insurance eligibility or financial
status.
____________________________________________________________________________
Patient signature Date Relationship (if other than patient)
Prescriber Certification
By my signature, I certify that the use of the indicated pharmaceutical product(s) is medically necessary.
I have no knowledge of any intent to sell, barter or give this product to any person other than the patient
for whom it has been prescribed. To the best of my knowledge, the patient has no medical/prescription
insurance benefits for the indicated pharmaceutical(s), including Medicaid or other public programs
other than as indicated, and the patient has insufficient financial resources to pay for the prescribed
therapy.
_____________________________________________________________________________________
Prescriber signature (Original signature required. Stamped signature not accepted) Date
Advocate Certification
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 any intent to sell, barter or give this product to any person other than
the patient for whom it has been prescribed. To the best of my knowledge, the patient has no
medical/prescription insurance benefits for the indicated pharmaceutical(s), including Medicaid or other
public programs other than as indicated, and the patient has insufficient financial resources to pay for the
prescribed therapy.
_____________________________________________________________________________________
Advocate signature (Original signature required. Stamped signature not accepted) Date