Complete the enrollment form on the reverse side to join
Onyx 360 today.
Oncology Nurse Advocates are available Monday through Friday, from 9 am to 8 pm Eastern
Standard Time at 1-855-ONYX-360 (1-855-669-9360) to help guide you and your patients through the specifics of the program(s) and answer any questions you or your patients might have.
Onyx Pharmaceuticals 360 PO Box 220785
Charlotte, NC 28222-0785
Onyx, Onyx Pharmaceuticals, Onyx Pharmaceuticals logo, and Onyx Pharmaceuticals 360 are all trademarks of Onyx Pharmaceuticals, Inc.
Onyx 360 is a comprehensive, personalized program designed to provide information and assistance to patients in their health journey, including
! Reimbursement Assistance
• Co-pay/co-insurance assistance through independent third-party foundations • Information and assistance with insurance
verifications
• Prior authorization and appeals process information
! Free product assistance for uninsured patients or those rendered uninsured through payer denial who meet certain income eligibility criteria
! Referral to third-party organizations for those patients who qualify and need assistance with or help paying for gas, lodging, tolls, and parking in
connection with receiving therapy
! Referral to support services for patients, families, and caregivers that provide product information, support group information, nutritional information, side effect management, along with practical matters related to the patient’s condition
Please complete the enrollment form for service(s) requested. Failure to include all information will delay the process. Please see required information below for each requested service. All services are subject to eligibility requirements.
! Insurance Verification
• Complete sections 1 2 3 5
• Physician signature and patient verbal or written authorization are required
• Fax a copy of the front and back of the patient's insurance card with the enrollment form
! Free Product Assistance
• Complete sections 1 2 4 5
• Patient’s financial documentation will be required (i.e., most recent 1040 federal tax return, W2, or Social Security statement) • Physician and patient signatures are required
! Independent Foundation Co-pay Assistance
• Complete sections 1 2 3 5
• Physician signature and patient verbal or written authorization are required
! Referral to Transportation and Lodging Cost Assistance
• Complete sections 1 2 5
• Physician signature and patient verbal or written authorization are required
! Referral to Patient Support Services
• Complete sections 1 2 5
• Physician signature and patient verbal or written authorization are required
Physician Declaration
I certify that the patient and physician information contained in this enrollment form is complete and accurate to the best of my knowledge and that I have prescribed based on my professional judgment of medical necessity.
If requested, I authorize Onyx 360 to perform a preliminary assessment of insurance verification for the above-named patient, and I further authorize and request that I am provided with all information necessary for me to complete a Letter of Medical Necessity for my patient, as may be required as a result of such insurance verification assessment. If my patient is approved for free product assistance by Onyx 360, I certify that neither I nor anyone on my behalf shall submit a claim to any third-party payer for payment of product provided under Onyx 360. I will ensure that any patient receiving free product assistance by Onyx 360 who is enrolled in a federal healthcare program such as Medicare or Medicaid will receive such free product during the entire time that patient is enrolled in this program, regardless of whether a federal healthcare program payer subsequently determines that it will cover the product during that time.
I will check with my local Medicare contractor, my state Medicaid program, or the appropriate payer to confirm whether and how I should reflect the no-charge dose on claims submitted for the associated procedure. I warrant that any product provided to me under Onyx 360 will only be used for the approved patient and will not be sold, traded, or returned for credit required.
Prior to transmittal of any personal health information (PHI), I certify that I have obtained the legally required patient verbal or written authorization for services selected above.
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ZIP
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I I I I I I I I, will I (i) I (ii) I (iii) I I I I
My signature at right certifies that I agree to join the Onyx 360 patient support
program and that I have read, understand, and agree to the Privacy Notice and Patient Authorization to release my personal health information as described in full detail on the following pages.
Uses and Disclosure of Personal Information
I authorize Onyx Pharmaceuticals, Inc., an Amgen subsidiary, and its contractors (“Onyx”) to use and/or disclose my personal information,
including my personal health information, for the following
purposes:
• To enroll me in and/or continue my participation in the ONYX 360 program or any other third-party patient support services and related activities;
• To contact, upon my
permission, my health care team (including my doctor and his team) and share with them some of my important health information;
• To provide me with
informational and marketing materials relating to Onyx products and services, and/or my condition or treatment; and/or
• To improve, develop, evaluate and continue products, services, materials and programs related to my condition or treatment. I also authorize any health care providers, health care plans, pharmacies, pharmaceutical companies, laboratories and/or their contractors (“Health Care Providers”) to disclose any of my
personal health information to
Onyx and its contractors as requested by Onyx and as
necessary for the purposes stated
in this Authorization.
I understand that my personal health
information includes any information,
in electronic or physical form, in the possession of or derived from a health care provider, health care plan,
pharmacy, pharmaceutical company, and/or contractor regarding: (1) my medical history, including my entire medical file and complete patient history; (2) my health care plan benefits; (3) limits or restrictions on payments covered by my health care plan policy; and/or (4) my health or my adherence to my treatment.
Expiration, Right to Obtain a Copy and Right to Cancel
I understand that Onyx may use my personal information, including my
personal health information, for five
years once I sign this Authorization or for a shorter time period if required by state law. I am entitled to receive a copy
of this Authorization.I also understand
that I can cancel this Authorization at any time by calling 1-855-ONYX-360
such Health Care Providers once they actually receive notice of my
cancellation from Onyx. No Effect on Treatment
I understand that the Onyx 360 program providers will receive compensation from Onyx for providing Onyx 360 services. I
understand that I do not have to agree to the uses and disclosures of my personal information contained in this
Notice and Authorization. I
understand that Onyx, as well as Health Care Providers, cannot require me, as a condition of
receiving medications, prescription drugs, treatment or other care, to
sign this Authorization. However,I
also understand that Onyx cannot provide me with any of the services contained in the Notice and
Authorization without my
authorization, including but not limited to, my enrollment or continued participation in patient support services. Under these
circumstances, I may be responsible for the full costs of my treatment.
Information Received from Health Care Providers
I understand that where a Health Care Provider discloses my personal
health information to Onyx for the purposes contained in this Notice and Authorization, the personal health information disclosed may not be covered by any federal law relating to the use of my personal health information or how it is disclosed. There is no guarantee that my
personal health information received by Onyx from a Health Care
Provider might not be released to a third party. I further understand that if a Health Care Provider is
disclosing my personal health
informationon an on-going basis to
Onyx, this Authorization only
permits Health Care Providers to do so for 1 year once I sign it or a
shorter time period if required by state law.
I understand that I may choose to be contacted by Onyx by mail,
e-mail, phone, and/or SMS/text, as indicated above, for any of the
purposes stated in this Authorization
andthat such communications may