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The form collects prescriber and clinic details, shipping information, insurer/income status confirmation, and a detailed administration log including administration dates, product replacement dates, dosage, number of vials, vial size, physician signature, and date. 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Please retain a copy for your files.  \nBY SUBMITING THIS FORM YOU CERTIFY: You have not received and will not seek reimbursement or payment for any part of the benefit received by the patient through the applicable program; any medication provided by Lilly Cares for this patient through any program in this application will not be resold, nor offered for sale, trade or barter, or returned for credit (except in the case of medication provided through the Product Replacement program which is replacing a separately purchased medication that has already been administered by you to the enrolled patient); if a retroactive insurer policy change allows for reimbursement of product already supplied at no charge, Lilly Cares will bill for the covered product, and you agree to be responsible for payment of the bill; and the information provided will be subject to potential random reviews. If you elect to receive medication through the Lilly Cares Foundation Patient Assistance Program under the Proactive Provision program you also certify: you will complete the required Administration Verification form confirming that the free product has been administered to the applicable enrolled patient; you will notify Lilly Cares if any free product is not administered to the applicable enrolled patient and will return the product to Lilly Cares for destruction or properly dispose the product in accordance with applicable regulations and submit documentation to Lilly Cares confirming that the product has been appropriately destroyed; and if you do not return or destroy and submit documentation for the free product provided not used for the applicable enrolled patient, you understand you will be billed for the product and you will be responsible for payment of the bill. Please contact Lilly Cares at 1-800-545-6962 for assistance with product returns.  \nIMPORTANT: This information is intended for the use of the person or entity to which it is addressed and may contain information that is confidential, the disclosure of which is governed by applicable law. If the reader of this information is not the intended recipient, or the authorized agent or individual responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you received this document in error, please notify us immediately and destroy the related document.  \nPP-AP-US-0392 10/2019 ©Lilly USA, LLC 2019. All rights reserved.","cbCaimJSmScNAolZ","https://ap.wps.com/l/cbCaimJSmScNAolZ","pdf",24152,"English","# Dose Tracking/Administration Form\n## Request purpose and submission guidance\n## Prescriber and clinic information\n## Administration log fields\n## Certifications and confidentiality notice","[{\"question\":\"What is this Dose Tracking/Administration Form used for?\",\"answer\":\"It is used for product replacement or proactive provision requests under the Lilly Cares Foundation Patient Assistance Program.\"},{\"question\":\"When should the form be submitted for proactive provision?\",\"answer\":\"For proactive provision requests, submit the form at least two weeks prior to the anticipated administration date.\"},{\"question\":\"What does the submitter certify by submitting the form?\",\"answer\":\"The submitter certifies that no reimbursement or payment will be sought, the medication will not be resold or traded, and the provided information may be subject to random reviews.\"}]","Lilly Cares Oncology - Dose Tracking/Administration Form | PDF",1789841757]