What is a Notice to Health Care Providers and Insurers?
Notice to Health Care Providers and Insurers: This form of authorization may not comply with all applicable Federal and state laws governing disclosure of the applicant’s information to the Program and its contracted third parties. The Program urges all entities disclosing information about the applicant to consult with legal counsel prior to relying on this form.
What happens if you receive a completed application for a syringe?
Upon receipt of a completed application, the patient will be notified of program eligibility. The approved supply of product will be shipped to the patient’s home unless otherwise specified.
