INSURANCE INFORMATION

FINANCIAL INFORMATION

(Fields marked with * are mandatory)

PROOF OF INCOME SELECTION

All patients will be required to provide proof of income. Proof of income includes spouse’s and dependents’ income as listed on application.

Acceptable forms of income documentation include:

• Federal income tax return or forms (1040, 1040EZ, 1099, 1099-DIV or I)
• Please cross out any Social Security numbers.

If a patient does not file, other acceptable forms of income documentation include:

• Yearly benefits statement (SSA, 1099, or awards letter)
• Pay stubs
• Unemployment letter or workers’ compensation
• Veterans’ benefits, alimony/child support, rental income, etc
• Employer letter on company letterhead
• Zero income letter from social worker, clergy, physician, or patient/family explaining how patient surviving on no income

Number in household must be provided. Only spouse and tax dependents are classified as part of household for financial determinations.

PATIENT DECLARATION

By providing my signature below, I, the patient applicant, agree to participate in the FUROSCIX Direct® Patient Assistance Program and to the terms of this program. I attest that all information provided on this Patient Assistance Program application is current, complete, and accurate. I understand that such information will be reviewed and relied upon to determine my eligibility for enrollment in the FUROSCIX Direct® Patient Assistance Program (“PAP”). I understand that completing this enrollment form does not guarantee that I will qualify for the FUROSCIX Direct® PAP program. I understand that the FUROSCIX Direct® PAP program may request additional documentation from me to verify my financial or insurance information, and that any assistance in the form of free medication is contingent upon my ability to meet the FUROSCIX Direct® PAP program eligibility criteria. I understand scPharmaceuticals reserves the right at any time and without notice to modify or discontinue the FUROSCIX Direct® PAP program and its eligibility criteria or terminate my enrollment in the FUROSCIX Direct® PAP program. I agree to notify and shall be responsible for notifying the FUROSCIX Direct® PAP program if my financial information or insurance coverage changes.

I agree that I will not seek reimbursement or submit a claim for scPharmaceuticals medication(s) provided through the FUROSCIX® Direct PAP program to any insurance provider, payer, health plan, or government program, or seek to have scPharmaceuticals medication(s) or any cost associated with it counted as part of my out-of-pocket cost for prescription drugs. I agree I will notify my insurance provider of my receipt of scPharmaceuticals medication(s) provided through the FUROSCIX Direct® PAP program. I understand that any scPharmaceuticals medication supplied by the FUROSCIX Direct® PAP program shall not be sold, traded, or transferred.

PATIENT HIPAA AUTHORIZATION

I authorize my healthcare providers, pharmacies, insurance providers, and payers to use, share, and disclose my personal and health information, including information about my insurance benefits, prescriptions, medical condition and history, adherence to my treatment and general health (“Personal Information”) with scPharmaceuticals and its service providers, agents, and administrators (collectively, the “Companies”) to: (1) establish my benefit eligibility; (2) provide support services, including facilitating the provision of scPharmaceuticals medication to me; and (3) contact me to evaluate therapy and the effectiveness of the FUROSCIX Direct® PAP program. I understand that once my Personal Information has been disclosed to the Companies, it may no longer be protected by federal privacy law and applicable state laws and may be re-disclosed. I understand that any entity authorized to support the FUROSCIX Direct® PAP program and any specialty pharmacies providing support to me in connection with the FUROSCIX Direct® PAP program may receive remuneration from scPharmaceuticals

I understand that I do not need to sign this authorization to receive healthcare treatment from my healthcare provider(s), insurance benefits, or enrollment in a health plan. However, I understand that if refuse to sign this authorization, I will not be eligible to participate in the FUROSCIX Direct® PAP program if I meet the eligibility criteria. I understand that if I sign this HIPAA Authorization, I may cancel my authorization at any time by calling 1-855-387-6724. This HIPAA Authorization will expire one year from the date it was signed or the maximum period permitted under state law, unless I cancel this Authorization at an earlier date.

I understand that my cancellation shall not apply to any of my Personal Information that has already been used or disclosed through this authorization before the FUROSCIX Direct® PAP program received notice of my cancellation. I understand that if I agree to sign this authorization, which I am not required to do, I must be provided a copy of this authorization.

If signed by Patient’s Representative, please complete the following:

*By signing above, I hereby declare that I have not been denied physical placement of this child nor have my parental rights been terminated by court order.

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