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XYREM® PATIENT ASSISTANCE PROGRAM APPLICATION

Personal Information
Name ___________________________________________Date of Birth ___/___/____ (mm/dd/yyyy)
Address _______________________________________ City ______________ State ____ Zip ______
Alternate
( _____ ) ______ - _____
Phone ( _____ ) ______ - _____________

Phone Number

Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___
Marital status: □ Single □ Married □ Widowed
□ Divorced
US Citizen: □ Yes □ No If NO, US Resident: □ Yes □ No Requires Green Card # __________or Visa #_________
U. S. Veteran: □ Yes □ No
Disabled: □ Yes □ No

Income Information
Total number of people in your household (yourself,
spouse, dependents): _______

Adults _____
Children _____
Monthly
Combined Household Income

Source of Income
Salary
Social Security
Unemployment Compensation
Alimony/Child Support
Disability Income
Pension/Retirement

$
$
$
$
$
$

Total combined assets (checking account, savings
account, stocks and bonds):
Do NOT include IRA, 401k

$ ____________________

Monthly Medical Expenses – please provide
proof

$ ____________________

Proof of Income: Do you have a copy of your federal income tax return from last year?
YES: Please send a copy of last years
Federal Income Tax Returns
for you, your spouse, & dependents

NO: If you didn’t file a federal income tax return last year,
you must send a copy of:
□ All income statements from jobs (W2 or 1099) OR
□ Social Security Income Yearly Benefits Statement

Insurance Information
Do you have any insurance that helps pay for any of your medication? ____ Yes ____ No
If yes, please answer below:
Is the prescription insurance a private or employer plan? ____ Yes ____ No
Do you have Medicaid? ____ Yes ____ No If yes, what state? _________________
Do you have Medicare Part D? ____ Yes ____ No _____
Do you have other Medicare? No ____ OR ____ Part A only ____ Part B only ____Part A&B only

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Consent

I give the Xyrem® Patient Assistance Program administrators, and my doctor permission to:
Check my information to make sure it is true and complete
Share my information with the Xyrem Success Program® and the pharmacy staff supplying Xyrem®
Contact me by mail or phone about the Program
I promise that:
All the information in this application, including all copies of documents proving my income and medical
expenses are true and complete
I am authorized to sign this application
I will contact the Program if any of my information about my prescription drug coverage or insurance
changes
I understand that the Program will only use my information to:
Decide if I qualify to participate in the Program
Administer or improve the Program
The Program can ask for more information from me at any time
The manufacturer of Xyrem® can change or stop the Program at any time or for any reason

Signature of Applicant or Legal Guardian
X___________________________________________________

Date _____________

Before you mail this application:
□ Attach a copy of last year’s federal income tax returns for yourself, spouse and dependents (or
other proof of income)

□ Attach a copy of all receipts for medical expense amount(s) stated on application
Mail completed and signed application to:
Xyrem® Patient Assistance Program
PO Box 66765
St. Louis, MO 63166-6765

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