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Additional consent covers collection, use, and disclosure of health information by Novo Nordisk and data processors for defined participation purposes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/pap-application-enrollment-year-consent-and-verification/194605/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/pap-application-enrollment-year-consent-and-verification/194605.png","ImageObject",442,249,{"name":42,"@type":43},"นรินทร์","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-07","2026-09-03",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be provided for patient and prescriber details?","Question",{"text":63,"@type":64},"The application requests patient identity and contact fields, including name, address, mobile number, email, DOB, gender, and household size, along with prescriber first and last name and prescriber phone number.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does the Medicare Part D enrollee consent authorize?",{"text":68,"@type":64},"If approved for PAP as a Medicare Part D enrollee, the patient (or legal representative) agrees that Novo Nordisk or PAP may share personal information with CMS to confirm Part D enrollment status and notify the patient’s Part D plan. The consent also sets expectations about receiving medication supplies and includes restrictions on seeking the Novo Nordisk medication from the Part D plan while receiving it from PAP.",{"name":70,"@type":61,"acceptedAnswer":71},"What is the purpose of the income verification consent under the FCRA?",{"text":72,"@type":64},"The consent authorizes PAP, Novo Nordisk, and authorized vendors to use electronic income verification, including a soft credit check, to determine financial qualifications for PAP programs. It also confirms the applicant’s instructions and that provided information is complete and true.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},194605,1788440654,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":33},2336475104957,"https://ap-avatar.wpscdn.com/avatar/22000c4c6bd8a5076e1?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787554080175789136","| Patient First Name*: |  |  | Patient Last Name*: |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Street Address* (NO PO BOX): |  |  |  |  |  |  |  |\n| City*: State*: |  |  |  |  |  |  | Zip*: |\n| Mobile Phone*: | Other Phone: |  |  |  | Email: |  |  |\n| DOB*: |  | Gender: Male Female Prefer not to disclose |  |  |  | Household Size: |  |\n| Prescriber First Name*: |  |  |  | Prescriber Last Name*: |  |  |  |\n| Prescriber Phone*: |  |  |  |  |  |  |  |\n| Do you have any form of prescription drug coverage*?\u003Cbr>If YES, please check ALL that apply and complete the information below* . Yes No\u003Cbr>Medicare (Part D) Prescription Coverage-must complete Section B\u003Cbr>Medicare Part B (medical benefit that covers some prescription medications)\u003Cbr>VA or Military Benefits Medicaid Prescription Drug Coverage\u003Cbr>Medicare Low Income Subsidy (LIS/Extra Help) Employer-supplied or commercial/private drug coverage |  |  |  |  |  |  |  |\n| Medicare Part D Enrollees – MUST COMPLETE ALL OF SECTION B |  |  |  |  |  |  |  |\n| Medicaid denial and/or Medicare LIS (Extra Help) denial is required if eligible for either program. Submit with your application.\u003Cbr>Medicare Part D Plan cards usually have “Medicare Rx” somewhere on the card. Medicare Advantage Plans with prescription coverage also have “Medicare Rx” somewhere on the card. |  |  |  |  |  |  |  |\n\n| Patient Medicare Prescription Drug Coverage (Part D) Enrollee Consent (if applicable) |  |  |  |\n| --- | --- | --- | --- |\n| I (or my parent/guardian/legal representative) agree that if I am (or the patient is) approved for PAP as a Medicare Part DEnrollee, Novo Nordisk or PAP may give my (or the patient’s) Personal Information to the Centers for Medicare & Medicaid Services (“CMS”) to confirm my (or the patient’s) Medicare Part D enrollment status and let CMS and my (or the patient’s) Medicare Part D plan know of this enrollment in PAP. Further, I (or my parent/guardian/legal representative) understand that upon approval, I (or the patient) will receive up to a 120-day supply of the medication(s) and/or device(s) from PAP through the end of this calendar year. I (or my parent/guardian/legal representative) agree that I (or the patient): (i) will not seek the requested Novo Nordisk medication(s) from my (or the patient’s) Medicare Part D prescription plan while receiving them from PAP; (ii) am not eligible for reimbursement for any medication dispensed by PAP from any government program or third-party insurer; and (iii) and will not apply any PAP medication(s) toward my (the patient’s) True-Out-of-Pocket (“TrOOP”) costs. |  |  |  |\n| | Patient, Parent, or Legal Representative Signature*:\u003Cbr>Required ONLY if patient is a Medicare Part D enrollee |  | Date*: |\n| PAP Application Enrollment Year: |  | Insurance ID*: |  |\n\n| First Name*: | Last Name*: | DOB*: |\n| --- | --- | --- |\n\n| Income Verification Consent [Fair Credit Reporting Act (FCRA)] * REQUIRED: SIGNATURE REQUIRED |  |  |  |\n| --- | --- | --- | --- |\n| PAP will perform an electronic income verification to process your application on your behalf.\u003Cbr>Please sign below to provide consent.\u003Cbr>I understand that I am providing “written instructions” under the Fair Credit Reporting Act (“FCRA”), authorizing PAP, Novo Nordisk, and its authorized vendor(s), on an ongoing basis as needed for the duration of my participation in programs administered by Novo Nordisk PAP, to obtain information from my credit profile or other information from the vendor through e-income verification, which will include a soft credit check, solely for the purpose of determining financial qualifications for programs administered by PAP. I understand that I must affirmatively agree to these terms in order to proceed in this financial screening process. I promise that any information, including financial and insurance information that I provide, is complete and true. I also understand that I may need to provide additional documentation and that additiona","cbCaieVDyGsQBk7h","https://ap.wps.com/l/cbCaieVDyGsQBk7h","pdf",334555,10,"English","# Patient and Prescriber Information\n## Address, Contact, DOB, and Prescriber Details\n# Prescription Drug Coverage Selection\n## Formulary Coverage Questions and Medicare Requirements\n# Medicare Part D Enrollee Consent\n## CMS Information Sharing and Medication Restrictions\n# Enrollment Year and Insurance Identification\n## Enrollment Year, Insurance ID\n# Income Verification Consent (FCRA)\n## Electronic Income Verification Authorization\n# Health Information Collection Consent\n## Data Use for PAP Purposes and Participation","[{\"question\":\"What information must be provided for patient and prescriber details?\",\"answer\":\"The application requests patient identity and contact fields, including name, address, mobile number, email, DOB, gender, and household size, along with prescriber first and last name and prescriber phone number.\"},{\"question\":\"What does the Medicare Part D enrollee consent authorize?\",\"answer\":\"If approved for PAP as a Medicare Part D enrollee, the patient (or legal representative) agrees that Novo Nordisk or PAP may share personal information with CMS to confirm Part D enrollment status and notify the patient’s Part D plan. The consent also sets expectations about receiving medication supplies and includes restrictions on seeking the Novo Nordisk medication from the Part D plan while receiving it from PAP.\"},{\"question\":\"What is the purpose of the income verification consent under the FCRA?\",\"answer\":\"The consent authorizes PAP, Novo Nordisk, and authorized vendors to use electronic income verification, including a soft credit check, to determine financial qualifications for PAP programs. It also confirms the applicant’s instructions and that provided information is complete and true.\"}]","PAP Application - Enrollment Year, Consent, and Verification | PDF"]