Pace – Medicaid Cancer Foundation

Patient Information

Full Names(Surname First):

D.O.B (DD/MM/YYYY):

Nationality

State of Origin

L.G.A:

Address:

Marital Status

Phone

Gender

Male Female

Occupation

How much do you earn monthly?

Email

How did you learn about this program?

How do you think this program will benefit you?

Next of Kin Details

Name

Relationship

Phone

Email

Address

Other Details

Have you ever volunteered, supported any organization or done community services before?

Yes (If yes, state details below) No

Name of Organization

Date

Details:

Have you taken Herceptin before?

If yes, How many vials have you had?

How and where did you purchase?

Patient Declaration & Authorization

I declare:

The information on this form is correct and complete including all copies of documents proving my inability to fund my treatment.

Not to sell or trade the product(s) provided under this patient assistance program.

To notify the MCF within seven (7) days if there is any change in my eligibility to participate in the program.

Not to attempt a claim or submit any costs associated with the subsidy on medicine(s) I receive under Pace.

I authorize the following communications:

To collect, use, disclose and/or process my personal data in order to process, administer, facilitate, maintain and/or manage my relationship with MCF as a beneficiary, including communications on MCF activities, programs and services and donation requests, carrying out research, analysis and development activities for MCF purposes and making disclosures required by law or a competent authority.

To contact me, requesting my assistance with analysis related to the quality and efficacy of the medication/programme.

For the manufacturer of a medicinal product or its agent to contact me or my healthcare provider for additional information, if needed, to evaluate any adverse event or product complaint I or my provider may have reported.

MCF reserves the right without notice to change the application form, change the program or program eligibility criteria or stop assistance provided by the program at any time.

This Authorization will last until I am no longer participating in the Program.

Upload Signature

Choose a file

Max. size: 10.0 MB

Date

Patient Consent

Patient Name:

Patient Signature:

Date:

If applicable, your representative must sign below:

Patient Representative Name:

Email:

Phone:

Upload Signature

Choose a file

Max. size: 10.0 MB

Relationship to patient and authority to make medical decisions for patient:

Attestation by Treating Physician

Patient Name:

Gender:

Male Female

Date of Birth:

Nationality

Hospital:

Hospital: No

Diagnosis:

Stage

Provide details of patient’s treatment plan and how many cycles patient will require

Doctor in Charge:

Contact Phone:

Email

I attest that the above named patient meets the eligibility criteria of this programme.

Upload Signature

Choose a file

Max. size: 10.0 MB

Patient Information

Full Names(Surname First):

D.O.B (DD/MM/YYYY):

Nationality

State of Origin

L.G.A:

Address:

Marital Status

Phone

Gender

Occupation

How much do you earn monthly?

Email

How did you learn about this program?

How do you think this program will benefit you?

Next of Kin Details

Name

Relationship

Phone

Email

Address

Other Details

Have you ever volunteered, supported any organization or done community services before?

Name of Organization

Date

Details:

Have you taken Herceptin before?

Have you taken Herceptin before?

If yes, How many vials have you had?

How and where did you purchase?

Patient Declaration & Authorization

I declare:

I authorize the following communications:

Upload Signature

Date

Patient Consent

Patient Name:

Patient Signature:

Date:

If applicable, your representative must sign below:

Patient Representative Name:

Email:

Phone:

Upload Signature

Relationship to patient and authority to make medical decisions for patient:

Attestation by Treating Physician

Patient Name:

Gender:

Date of Birth:

Nationality

Hospital:

Hospital: No

Diagnosis:

Stage

Provide details of patient’s treatment plan and how many cycles patient will require

Doctor in Charge:

Contact Phone:

Email

I attest that the above named patient meets the eligibility criteria of this programme.

Upload Signature

Date

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