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 didnt 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 years 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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