I understand Alliance Labs will review my enrollment form, determine my eligibility, and notify me based on the information I provide. The administrator may at any time require additional information to determine or confirm my eligibility. If I am eligible, I will receive notification by phone, mail or email.
Savings under the program do not apply to products reimbursed under any federal or state program, including Medicaid or any private insurance, HMO, Medigap, employer, or other third-party arrangement ("private insurance"). By signing the enrollment form I certify that if I do not have any prescription drug coverage, I have contacted an insurance broker and have been turned down. This program is valid only to legal U.S. residents. The program may be terminated or modified at any time. Alliance Labs reserves the right to revise or revoke this program at any time. If any such revision or revocation occurs, the applicant will be notified either by phone or mail. Quantity restrictions do apply. Each approved participant in this program will not be allowed more than three 30 day supply per calendar month. Promotional discounts and free/discounted shipping offers are not valid with patient assistance program. Patients seeking additional purchases may be required to provide a physician order.
AUTHORIZATION TO USE AND DISCLOSE INFORMATION
I understand that Alliance Labs and the administrator of the program will receive information about me. I authorize Alliance Labs to:
• Use that information to administer the program and to communicate with me.
Alliance Labs does not provide/sell personal information to third party companies. I may revoke this authorization by ending my participation in the program by writing to Alliance Labs, 1406 West Victory Lane, Phoenix, Arizona 85027 or by phone at 1-888-273-9734 Ext. 208 or email customer service at email@example.com.
1. I am a legal resident of the United States.
2. My current prescription insurance, if any, does not cover Enemeez ®.
3. I have Medicaid or Medicare, however my State will not cover Enemeez ® at this time.
4. I have a household income equal to or less than:
• $23,500 for a single person
• $31,500 for a family of two
• $39,500 for a family of three
• $47,500 for a family of four or more
Date of birth
Did you file a tax return for the most recent year?
Annual Household Income
Number of people in your household (including yourself and spouse, if married)
May we contact you?
By checking YES, you agree that Alliance Labs may contact you about new programs and services, additional products and health information or for market research purposes. If No, Alliance Labs LLC may continue contacting you for transactional details (order confirmations, shipping, etc.), recalls, and other pertinent information.
YOUR MUST INCLUDE ACCEPTABLE PROOF OF INCOME
Acceptable proof of income documents include
• Federal Income Tax Form (1040, 1040A, or 1040EZ, 1040X, 1722, 8453, 8879, or 100INT)
• Yearly Benefits Statement (SSA 1099 or 4506T)
• IRS Telefile worksheet
• W2 Tax Statement
• Social Security, Pension, or Railroad Retirement Statements (SSA-1099, 4506T)
• Statements of interest, dividends, or other income (1099-INT, 1099, 1099T, 1099-DIV)
Please upload all requested documentation so we may properly process your application for the Patient Assistance Program (Drag and Drop, Multiple Files Accepted)
Additional Uploads (If necessary)
Additional Uploads (If necessary)
By signing, I certify that I have read and understand the program information on this form. Additionally, I certify that the information on this enrollment form, including all copies of income documentation, is accurate and complete and that I am authorized to sign this application. I understand and agree that an administrator of this program will verify my information.