Pharmacy Assistance Program Income Qualification

Please input the range of your pre-tax household yearly income. 
This information is used solely to verify Federal Poverty Level (FPL) and apply potential pharmaceutical savings and will not be shared with any third-party.

I. Demographic Build & Tobacco Use

• Answer all of the following questions for yourself and enrolling family members. 
• All questions must be answered, or the form may not be accepted.

Child #2

II. Medical Conditions & Treatments

Has any person listed above seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following within the last 5 years?

Check 'YES' or 'NO' for each question.  
Please complete ADDITIONAL DETAIL SECTION for ALL 'Yes' answers

List the three most recent HbA1c/fasting blood sugar levels

List the three most recent Cholesterol readings:

List the three most recent readings:

24. Is anyone currently:

25. Is any of the following pending?

III. Pregnancy and Childbirth

Additional Details

Please answer the following questions below for ALL above questions answered 'YES'

#1: Cancer

#2 Cardiac or Heart Disease

#3 Diabetes

#4 High Cholesterol

#5 High blood pressure

#6 Arthritis

#7 Autoimmune Disease

#8: Back Disorder

#9: Benign Growth

#10: Bowel

#11: Circulatory System Disease

#12: Immunodeficiency

#13 Kidney Disorder

#14: Liver Disease

#15: Mental Illness

#16: Counseling

#17: Muscular Disorder

#18: Respiratory

#19: Stomach

#20: Substance dependency

#21: Transplants

#22: Prescription Medication (1)

#23a: TREATMENT for a serious illness in last 5 years

#23b: HOSPITALIZATION for a serious illness in last 5 years

#23c: SURGERY for a serious illness in last 5 years

#24a: CURRENTLY hospitalized or confined in a treatment facility

#24b: CURRENTLY confined at home, incapacitated, or incapable of self support

#25a: PENDING TREATMENT (medical or diagnostic)

#25b: PENDING HOSPITALIZATION

#25c: PENDING SURGERY

 #26: SYMPTOMS of a serious illness in last 5 years

#27: PREGNANCY: Is anyone pregnant

#27b: PREGNANCY: High Risk, complications, bleeding

#27c: PREGNANCY: Previous c-section or pre-term birth

PHI DisclosureBy signing this application, I understand the following:  That if any information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind healthcare coverage.  In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage, minus administrative expenses and claims paid. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information purposes only and does not bind coverage. I understand the AAHP gathers this information for statistical and actuarial uses only and it will not be used in connection with decisions or actions regarding employment.  That if I am a resident in Michigan, I do not have to provide information regarding height or weight, and that this in compliance with requirements for GINA.  That I have read the Client Privacy Notification provided to me in this application.  That as a prospective member, I have the right to request restrictions on how my protected health information is used, and that the AAHP is not required by law to grant this request, but if the request is granted, the AAHP is bound by this agreement. I also understand that I have the right to revoke this consent in writing, except to the extent the AAHP Program has already used or disclosed the protected health information in reliance upon my consent. I further understand that the AAHP program will notify me the member of any health or enrollment related changes that occur after signing this form, up to the effective date of coverage. I understand that this process is required in order to make eligibility or enrollment determinations relating to me, my spouse and/or my dependents and for underwriting to make risk rating determinations. I further understand that my application for enrollment based on the information provided may be refused.

Client Privacy Notification
Thank you for completing the requested information. Any information, including non-public personal health information, such as name, address and social security number, including detailed protected health information provided will be used for the sole purpose of providing a risk assessment to the health plan that will provide a health care benefit quote to your employer. The AAHP's actuary is a legally contracted underwriter acting as a Business Associate to the AAHP Program and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The AAHP's actuary and underwriter will not sell, license, transmit or disclose this information outside of their offices except as: a) necessary for them to provide the services on behalf of the  health plan,  b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law.