Fill in a Valid Bridges Access Application Template

The Bridges Access Application form is a critical tool designed to help individuals access essential medications through a patient assistance program sponsored by GlaxoSmithKline. This program provides qualifying applicants with the medicines they need, depending on their household income and insurance status. To take the first step toward receiving assistance, fill out the form by clicking the button below.

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The Bridges Access Application form serves as a crucial tool for individuals seeking assistance with GlaxoSmithKline medications. This form is part of a patient assistance program aimed at making prescription medicine more accessible for those who meet specific eligibility criteria, which include household income and insurance status. To begin the application process, applicants must provide detailed information, such as personal identifying details, income documentation, and the specific prescriptions required. Once a completed application is submitted, applicants will receive notification by mail regarding their eligibility status. If qualified, individuals will be able to receive a 90-day supply of medicine, with the possibility of renewing their participation annually. The form also includes sections for essential health information, any prescription coverage that the applicant may have, and the option to specify a different shipping address for the medication. It is important to fully complete the application to avoid delays, and additional resources are available through the program’s website or by phone for those who may have questions during the process.

Bridges Access Application Example

Bridges to Access

PO Box 29038

Phoenix, AZ 85038-9038

1.866.PATIENT (1.866.728.4368) www.BridgesToAccess.com

Bridges to Access is a patient assistance program sponsored by GlaxoSmithKline that provides GlaxoSmithKline medicines to applicants who meet eligibility requirements. Eligibility is based on household income and insurance status. To apply, send a completed application along with income documentation and prescriptions for GlaxoSmithKline medication to the address above. Applicants will be notiﬁed by mail if they qualify for the program. If approved, the applicant will be eligible to receive medicine for up to one year and the ﬁrst 90-day supply will be sent by mail. Applicants must re-apply annually. Additional information about eligibility requirements and how to complete this form can be obtained at www.BridgesToAccess.com or by calling 1.866.PATIENT.

APPLICANT INFORMATION

Name (First):________________________________ (M.I.): _________ (Last):_______________________________________

Mailing Address:_______________________________________________________________________________________

City:___________________________ State:______ ZIP Code:___________ Phone Number: ( _______ ) _______ - __________

Number of people, including the Applicant, who contribute to or are dependent on the household income?

DD YYYY

Gender:

Social Security #:

Birth Date: _____ /_____ /______

M r F r

Total Gross Monthly Income: ___________________

OR Gross Annual Income: _______________________________________

If the applicant ﬁled income tax or was listed as a dependent on someone else’s income tax for the most recently ﬁled tax year, attach a copy of page one of the tax form (acceptable tax forms are 1040, 1040A or 1040EZ only). If no tax form was ﬁled or if the tax form does not represent current income, attach proof of income from all sources for the most recent 30-day period for the applicant and all members of the household. Include pay stubs, unemployment stubs, Social Security statements, pension statements, etc.

PRESCRIPTION COVERAGE

1.	Is the applicant eligible for any state or federal prescription drug program such as Medicaid?	Yes r	No r
2.	Does the applicant have any private prescription drug coverage?	Yes r	No r

If yes to either of the above, please indicate why assistance is needed:

Medicine not on plan drug list r	Pre-existing condition r	Over plan coverage limit r
Other (please explain) r _____________________________________________________________________
3. Is the applicant enrolled in a Medicare Part D prescription drug plan?		Yes r No r

SHIPPING ADDRESS Only complete this section if medicine is being shipped somewhere other than the Mailing Address above.

Addressee or Business Name:_________________________________________________________________________________

Street Address:_________________________________________________________________________________________

City:____________________________________________________________ State:______ ZIP Code:__________________

Specify addressee’s relationship to the applicant: Self r Prescriber/Advocate r (must complete Prescriber/Advocate Information on Page 2) Other (specify relationship) r ___________________________________________

ALLERGY AND HEALTH INFORMATION

List any known drug allergies and health conditions: ________________________________________________________________

____________________________________________________________________________________________________

REMEMBER TO:

rComplete the entire form. An incomplete application will delay processing. Call 1.866.PATIENT (1.866.728.4368) or visit www.BridgesToAccess.com with any questions about how to complete this form.

rMail the following:

u Completed and signed application.

u Proof of income. If the applicant ﬁled income tax or was listed as a dependent on someone else’s income tax for the most recently ﬁled tax year, attach a copy of page one of the tax form (acceptable tax forms are 1040, 1040A or 1040EZ only). If no tax form was ﬁled or if the tax form does not represent current income, attach proof of income from all sources for the most recent 30-day period for the applicant and all members of the household. Include pay stubs, unemployment stubs, Social Security statements, pension statements, etc.

u Signed original prescription(s) for GlaxoSmithKline medication written for a 90-day supply with reﬁlls if medically appropriate.

rKeep a copy of the application and all documents for your records. Please print applicant’s name and date of birth on all documents.

PAGE 1

REQUIRED SIGNATURE ON PAGE 2

APPLICANT AUTHORIZATION TO RELEASE AND DISCLOSE MEDICAL INFORMATION

By my signature I authorize GlaxoSmithKline, as well as McKesson Specialty Arizona Inc. (MSAZ) and any other companies that GlaxoSmithKline uses to administer Bridges to Access (the “Program”), to do the following:

1)Use any information that I provide in my application for the Program for the purpose of helping me receive GlaxoSmithKline products under the Program or to administer the program;

2)Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the program;

3)Contact my doctor, healthcare provider, or pharmacist about my application for the Program, and disclose to them information contained in my application, in order to help me receive GlaxoSmithKline products under the Program and ensure that Program guidelines are being met;

4)Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to administer the Program. By signing below, I also authorize my insurer, doctor, healthcare provider, or pharmacist to release information about my prescribed medications and medical condition that is requested by GlaxoSmithKline, MSAZ or any company that GlaxoSmithKline uses to run the Program;

5)Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage or other funds, and disclose to them information contained in my Program application or information about my prescribed medications and medical condition that has been provided by my physician, healthcare provider, or pharmacist;

6)Disclose any information obtained from the sources listed above to third parties if required by law.

I understand that this Authorization to Release and Disclose Medical Information will remain in effect for as long as I participate in the Program and for a period of 3 years after my participation in the Program ends.

I understand that my healthcare providers will not condition my medical treatment on my agreement to sign this Authorization to Release and Disclose Medical Information. I also understand that I have the right to revoke this authorization at any time by calling 1.866.PATIENT (1.866.728.4368) and

mailing a signed written statement of my revocation to the Program. Such a revocation would end my eligibility to participate in the Program. Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been taken in reliance on my authorization.

I understand that once medical information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by federal privacy laws and may be further disclosed.

I understand that GlaxoSmithKline does not charge a fee for participation in this Program. There is a copayment for each prescription ﬁlled at a retail pharmacy. If my advocate charges a fee for enrollment or reﬁlls of my medicine, this money is not paid to GlaxoSmithKline.

I certify that I am not enrolled in any Medicare plan that includes Part D drug coverage. Furthermore, I certify that the information provided in this application is complete and accurate to the best of my knowledge and agree to notify GlaxoSmithKline of any change in my insurance eligibility or ﬁnancial status.

______________________________________________________	____________	________________________________________
Applicant Signature	Date	Relationship (if other than Applicant)

OPTIONAL: ADVOCATE INFORMATION

This section should be completed only if the advocate enrolls the applicant and wants to be the contact person and receive program correspondence for this applicant.

Advocate ID Number: ______________ (You must be a registered advocate. Register at www.BridgesToAccess.com or by calling 1.866.PATIENT)

Name (First):________________________________ (M.I.): ____________ (Last):_______________________________________

Facility Name:__________________________________________________________________________________________

Street Address: ____________________________________________________________________________________________

City:_________________________________________________________________ State:_______ ZIP Code:____________

Phone Number: (_______) _________-______________________ Fax Number: (_______) _________-_______________________

By my signature, I certify to the best of my knowledge, the information on this application is correct and complete. I have no knowledge of any intent to sell, barter or give this product to any person other than the Applicant for whom it has been prescribed. To the best of my knowledge, the Applicant has no medical/prescription insurance beneﬁts for the indicated pharmaceutical(s), including Medicaid or other public programs other than as indicated, and the Applicant has insufﬁcient ﬁnancial resources to pay for the prescribed therapy.

___________________________________________________________________	________________________________________
Advocate Signature (Original signature required. Stamped signature not accepted.)	Date

PAGE 2

BtA Mail Rev. 04/10

Click for Bridges Access Application File

File Breakdown

Fact Name	Description
Program Sponsor	The Bridges to Access program is sponsored by GlaxoSmithKline, aimed at providing access to their medicines for eligible patients.
Eligibility Criteria	Eligibility for the program depends on the applicant's household income and insurance status.
Application Submission	Applicants must submit a completed application along with income documentation and a prescription for GlaxoSmithKline medications to the specified PO Box in Phoenix, AZ.
Notification of Outcome	Applicants will receive a notification by mail regarding their qualification status for the program.
Medicine Coverage Duration	If approved, participants can receive medications for up to one year, with the first 90-day supply sent via mail.
Annual Re-Application	Applicants must re-apply for the program annually to continue receiving assistance.
Contact Information	For queries regarding the application process, applicants can call 1.866.PATIENT or visit the official website at www.BridgesToAccess.com.
Required Documentation	Eligible applicants must include proof of income and signed prescriptions with their application.
Authorization to Release Information	Applicants must sign an authorization allowing GlaxoSmithKline and associated entities to access their medical information.
Medicare Certification	Applicants must certify they are not enrolled in any Medicare plan with Part D drug coverage to qualify for the program.

Guide to Using Bridges Access Application

Filling out the Bridges Access Application form is a process that can be completed in several straightforward steps. After submitting this application, you will receive a notification by mail regarding your eligibility for the program. If approved, assistance will be provided for a period of up to one year, ensuring access to necessary medications. Follow the steps below carefully to complete the application accurately and efficiently.

Begin with the Applicant Information section. Fill in your name, mailing address, phone number, and the number of people contributing to or dependent on your household income.
Provide your Social Security number, gender, and birth date.
Enter your total gross monthly or annual income. Attach documentation, such as tax forms or recent pay stubs, to verify your income.
Answer the questions regarding Prescription Coverage, indicating if you are eligible for state or federal programs, or if you have private prescription coverage.
If applicable, explain why assistance is needed in the space provided.
Complete the Shipping Address section only if the mailing address differs from your actual address. Specify the addressee's relationship to you.
List any known allergies and health conditions in the designated section.
Review the entire form for completeness to avoid processing delays.
Sign the application on page two and include any necessary authorizations.
Mail the application along with your proof of income and signed prescriptions for GlaxoSmithKline medication to the address provided.

Remember to keep a copy of your completed application and all submitted documents for your records. If you have any questions or need further assistance, contact the program via the phone number or website listed above.

Get Answers on Bridges Access Application

1. What is the Bridges Access Application form? The Bridges Access Application form is used to apply for the Bridges to Access program, which provides GlaxoSmithKline medications to eligible individuals. This program is designed to help those who may struggle to afford their prescribed medications.
2. Who is eligible to apply for the program? Eligibility is determined by household income and insurance status. Applicants must have a total gross monthly or annual income that falls below a certain threshold set by the program. Additional details can be found on the official website or by calling the patient assistance line.
3. What documents do I need to submit with my application? You will need to submit: A completed and signed application form. Proof of income for the applicant and household members for the last 30 days or a copy of the most recent tax form. Signed prescriptions for GlaxoSmithKline medications, written for a 90-day supply with refills if appropriate.
4. How will I know if I qualify for the program? Once your application is processed, you will receive a notification by mail indicating whether or not you qualify. It can take some time, so please be patient.
5. How long can I receive medications through this program? If approved, you will be eligible to receive medications for up to one year. After that, you will need to reapply for continued assistance.
6. What if my financial situation changes after applying? If there are changes in your financial situation or insurance status, you are required to notify GlaxoSmithKline right away. This will ensure that your eligibility for the program can be reassessed in a timely manner.
7. Can I receive help if I already have some form of insurance?
8. Where can I find more information on completing the application? More information about the application process, eligibility requirements, and other inquiries can be found at www.BridgesToAccess.com or by calling the patient assistance line at 1.866.PATIENT (1.866.728.4368).

Common mistakes

Applying for the Bridges Access Application can be a significant step towards receiving the medications you need. However, many applicants make common mistakes that can hinder their chances of approval. Understanding these pitfalls can help you navigate the application process more effectively.

One frequent error is failing to provide complete information. The application form requires detailed personal and income information. Omitting any part or misplacing essential details can lead to delays in processing your application. It’s crucial to review the form thoroughly to ensure every section is filled out completely.

Another common mistake is neglecting to attach the necessary documentation. Applicants must include proof of income, such as pay stubs or tax forms, with their application. Without this documentation, your application may be deemed incomplete, causing further delays. Always double-check that all required documents accompany your submission.

Some individuals mistakenly assume that their prescriptions are sufficient documentation. While you do need to include a copy of your prescriptions, this alone is not enough. The forms specifically stipulate that income verification is also necessary, emphasizing the importance of including both sets of information.

Misunderstanding the eligibility criteria can also lead to issues. Applicants may fill out the form incorrectly due to a lack of clarity on their insurance status. If you are enrolled in any type of insurance that covers your medications, including Medicare Part D, it is essential to disclose this information accurately. Failing to do so may disqualify your application.

Another misstep is neglecting to sign and date the application. This final step is often overlooked but is critical. Without a signature, the application is considered invalid, and you will need to start the process over again. Always ensure you have signed where required before sending your application.

Lastly, applicants sometimes forget to keep copies of their submissions. Retaining a copy of your application and related documents can be invaluable for your records. It allows you to track what you submitted and to follow up if needed in the future. Staying organized can prevent unnecessary hassles later in the process.

By avoiding these common mistakes, you increase your chances of a successful application. Thoroughly reviewing your information and ensuring all necessary components are attached will set a strong foundation for your submission to the Bridges Access Program.

Documents used along the form

When applying for assistance through the Bridges to Access program, applicants often need to submit not only the Bridges Access Application form but also a set of important supporting documents. These documents help verify eligibility and streamline the application process. Below is a list of commonly required forms and documents that accompany the application.

Proof of Income Documentation: Applicants must provide evidence of their household income. This may include pay stubs, Social Security statements, or unemployment benefit notices. If the applicant filed an income tax return, a copy of the first page of the tax form (1040, 1040A, or 1040EZ) is generally required.
Prescription(s) for Medication: A signed original prescription for the specific GlaxoSmithKline medication is needed. This prescription should ideally cover a 90-day supply and may include refills if appropriate for the applicant’s medical situation.
Authorization to Release Medical Information: This signed document allows GlaxoSmithKline and affiliated entities to access the applicant's medical records, ensuring they can verify eligibility and facilitate assistance effectively.
Advocate Information Form: If an advocate is submitting the application on behalf of the applicant, this optional form should be completed. It contains details about the advocate and their relationship to the applicant, allowing easier communication during the application process.
Verification of Eligibility for Other Programs: If the applicant is enrolled in any state or federal programs (like Medicaid), they may need to submit documentation that verifies this eligibility, as it can influence their application status.
Proof of Pharmacy Coverage: If the applicant has private prescription drug coverage, they may also need to provide documentation showing the specifics of that coverage, including any denials or limitations they are encountering.
Household Information: A detailed list of all individuals contributing to or dependent on the household income may be necessary. This information helps assess the overall financial situation of the applicant’s household.
Updated Contact Information: It’s essential to ensure that the contact details provided are current, including mailing addresses, email, and phone numbers, to facilitate quick communication regarding the application status.

Gathering these documents can feel overwhelming, but each item plays a critical role in establishing eligibility for the Bridges to Access program. By ensuring that all required paperwork is complete and accurate, applicants can enhance their chances of a swift and successful application process.

Similar forms

Patient Assistance Program Application: Similar to the Bridges Access Application, this form also helps patients access medications through a financial assistance program, requiring income verification and personal information.
Medicaid Application: Like the Bridges Access Application, a Medicaid application assesses financial eligibility and household income to determine whether an applicant can receive state-funded healthcare services.
Medicare Enrollment Form: This form is used by individuals seeking Medicare benefits, just as Bridges Access assesses eligibility based on various criteria, including financial status and healthcare needs.
Prescription Refill Request Form: Similar to Bridges Access, this form typically requires patient information and verifies the need for medications, emphasizing clear communication between patients and their healthcare providers.
Health Insurance Marketplace Application: This application determines eligibility for health coverage, paralleling the Bridges Access Application in its focus on household income and insurance status.
Social Security Disability Application: The process for applying for disability benefits follows a similar format, where documentation of financial hardship and personal details are crucial for qualification.
Charity Care Application: Much like the Bridges Access Application, this form gathers information on a patient’s financial situation to grant access to medical services or medications at reduced costs.
University Healthcare Assistance Application: In educational settings, this application allows students to request help with healthcare costs, collecting information on income and other factors, not unlike the Bridges Access form.

Dos and Don'ts

Things You Should Do:

Complete the entire application, leaving no sections blank.
Attach proof of income documentation for all household members.
Include signed prescriptions for a 90-day supply of GlaxoSmithKline medication.
Keep a copy of the completed application and all supporting documents for your records.

Things You Shouldn't Do:

Don't leave any sections of the application incomplete.
Don't forget to print the applicant’s name and date of birth on all submitted documents.
Don’t send the application without verifying all required enclosed documents.
Don’t assume eligibility without confirming household income and insurance status.

Misconceptions

Misconceptions about the Bridges Access Application form can lead to confusion and frustration. Here are nine common misconceptions, along with explanations to clarify them.

Only low-income individuals can qualify. While income is a factor, eligibility is determined by a combination of household income and insurance status. Applicants should assess their overall situation.
You must be uninsured to apply. The program is available to those with insurance as well. If the medicine isn't covered, applicants may still receive assistance.
Submitting the application is enough to receive medication. Applicants must also provide required documentation, including proof of income and prescriptions. Incomplete applications will delay the process.
You only need to apply once. Applicants must reapply annually to continue receiving medications through the program. Staying proactive is crucial.
The application process takes a long time. While processing times can vary, many applicants receive faster notifications. Timely submission of complete documentation helps speed up the process.
Bridges Access is only for specific medications. The program provides GlaxoSmithKline medications, but applicants should check the specific drugs available through the program.
Providing medical information is optional. To successfully process the application, necessary medical information must be provided. This is crucial for evaluating eligibility.
Application help is not available. Assistance is available by calling 1.866.PATIENT or visiting the website. Resources are provided to help applicants through the process.
Approval guarantees medication for life. Assistance is granted for one year, after which applicants must reapply. Continuous eligibility must be demonstrated.

Key takeaways

Filling out the Bridges Access Application form is an important step for those seeking assistance with GlaxoSmithKline medications. Here are some key takeaways to keep in mind when completing the application:

Ensure that you provide all required personal information, including your name, contact details, and household income.
Gather necessary documentation ahead of time; this includes your income proof and signed prescriptions for the medications you need.
Check your eligibility carefully. Factors such as household income and insurance status play a crucial role in whether you qualify.
Complete the entire form. Leaving parts blank may delay the processing and review of your application.
After mailing your application, be sure to keep a copy for your records. Include the applicant's name and date of birth on all submitted documents.
If you have questions or need assistance at any point, do not hesitate to call 1.866.PATIENT or visit the official website.

Be thorough and proactive, and you will set yourself up for the best chance of successful application outcome.

Fill in a Valid Bridges Access Application Template

Bridges Access Application Example

File Breakdown

Guide to Using Bridges Access Application

Get Answers on Bridges Access Application

1. What is the Bridges Access Application form?

2. Who is eligible to apply for the program?

3. What documents do I need to submit with my application?

4. How will I know if I qualify for the program?

5. How long can I receive medications through this program?

6. What if my financial situation changes after applying?

7. Can I receive help if I already have some form of insurance?