Telephone: 417-837-2270
640 East Cherry, #105
Fax: 417-837-2271
Springfield MO 65806
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CONFIDENTIAL
CONFIDENTIALITY NOTICE: The documents accompanying this transmission contain confidential information that is legally
privileged and belong to the sender. This information is intended only for the use of the individual or entity named above. The
authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy
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WELCOME TO MSU CARE
MSU Care is a collaboration between Missouri State University and Mercy Health Springfield Communities.
Our goal is to provide high quality primary care to qualified uninsured adults, ages 18-64, and serve as your
medical home. In addition, MSU Care will serve as a site for healthcare students and MSU faculty to be
involved in clinical practice. Your care will be provided by nurse practitioners, physician assistants, physicians,
and other members of the health care team. Our hope is that we can work together to: treat your short-term
diseases, manage your chronic conditions, and help you stay healthy. We welcome you to MSU Care and
thank you for choosing our clinic for your healthcare. The following includes information essential to your care.
PATIENT AGREEMENT
Rights and Responsibilities
As a partner in your healthcare, we will have responsibilities:
As your medical home, we will:
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Provide considerate and respectful quality care.
Provide routine outpatient care at no cost to you in the clinic. However, certain medications or
specialty care referrals may have a fee. You will be notified when a fee is involved prior to receiving
care, and whether you qualify for Charity Care.
Communicate information about your health in ways that you understand.
Connect you with other members of your care team (specialists, educators, case managers), and
coordinate your care with them.
Help you make the best decisions for your care.
Give you information about classes, support groups, or other resources/services that can help you
learn more about your condition and what you can do to stay healthy.
Notify you of test results in a timely manner.
Provide care during the hours we are open. After that time, you will need to go to the ER for
emergencies that cannot wait until the next day.
Honor your right to refuse treatment.
Honor your right to privacy and confidentiality.
As our patient, we trust that you will:
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Assume responsibility and take ownership for your own health and healthcare. Be encouraged to ask
questions about your care.
Provide us with accurate and current information and paperwork that we require to determine your
eligibility for care and medications. Income verification is required every 6 months. This information is
confidential and will not be released without your written permission or as required by law. Falsifying
income or insurance information is grounds for termination of MSU Care services.
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Update your patient and eligibility information if there are any changes.
As our patient, we trust that you will (continued):
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Have the right to be treated with respect and dignity regardless of your race, religion, gender,
ethnicity, sexual orientation, political affiliation, or disability.
Be allowed to refuse treatment, as allowed by law, and to be told what might happen to you medically
if this is your choice.
Not sell or give your medications to others.
Be open and honest about your health and health history, including alcohol and illegal drug use; your
eligibility for care; and if you are seeing other doctors or taking medications we have not prescribed.
Use the clinic as your primary health care source, and avoid using the Emergency Room unless you
have an emergency (accident, severe bleeding, impaired consciousness, etc.) that cannot wait until the
clinic opens the next day.
Follow your treatment plan and take medications as prescribed, or tell us why you are not following
and how we can help.
Not bring illegal substances, drugs not prescribed to you, weapons, or alcohol into the clinic.
Be courteous and respectful to all MSU Care clinic staff, providers, volunteers, and other patients.
Give us feedback to help us improve our care for you.
Understand that prescription refills and follow up care are your responsibility and should call MSU
Care at least two weeks before you need a prescription refill. Refills are provided only at provider
discretion.
NOTICES
Patients must acknowledge the following:
One of the goals of the MSU Care is to serve as a clinical site for healthcare professional students at MSU.
These students are always under the supervision of a healthcare staff.
MSU Care is limited in the services they can provide on-site. MSU Care will provide what services they are
capable of, but cannot provide all necessary healthcare and cannot treat all medical conditions. Therefore, any
other medical services provided outside of the MSU Care clinic at Mercy, will be subjected to Mercy's Charity
Care Policy. This would include, but is not limited to, specialty consultations, procedures, and professional fees
related to clinic performed x-rays and EKGs. If services are referred or required outside of MSU Care, you may
be responsible for the cost of the services and agree to hold MSU care, including all of its personnel and
volunteers, harmless.
POLICIES AND PROCEDURES
Eligibility Documentation
The clinic will require that you submit the following documentation at the time of care. Failure to provide all
of the documentation will cause you to have to reschedule your appointment to another day.
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Identification:
 current driver’s license, state identification card, or other valid identification
Income verification for all household income –
 Previous year’s federal income tax return
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Updated 8/19/2016
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4506T Form, if taxes were not filed
Two months of most recent pay stubs for everyone living in the household
Proof of eligibility of federal, state, or other income assistance including, but not limited to SSI,
SSD, VA, Worker’s Compensation, etc.
 A copy of a Medicaid Denial Letter
Statement of Support
 If you do not have a household income, you will need to fill out a statement of support that
shows how your needs are being met.
Keeping Scheduled Appointments
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MSU Care understands that situations may arise that do prevent you from keeping your appointment.
Please be courteous to us and other patients by calling at least 24 hours prior to your appointment to
cancel.
Patients arriving more than 15 minutes late for their appointments will be counted as a NO SHOW and
they will need to reschedule their appointments to another time and day. Come to your appointments
on time or provide 24-hour notice, if possible, when cancelling appointments.
If two appointments are missed within a 6-month period without notifying MSU Care in advance, you
will no longer be able to receive services at MSU Care. We will continue serving you only for the next
30 days in case of urgency until you find a new provider.
A missed referral appointment will be counted as a NO SHOW, and you may not receive any more
referral appointments through MSU Care.
MSU Care Policies
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No alcohol or street drugs are allowed at the MSU Care site at any time. Guns and other types of
weapons are not allowed at the clinic unless carried by a law enforcement officer or security
personnel.
No smoking will be permitted in the clinic, in the clinic entryway, or on the grounds of Missouri State
University.
Patients who are uncooperative, loud or disruptive in the waiting area, verbally or physically
threatening/abusive, intoxicated, or behave in an inappropriate manner will be dismissed from the
clinic and may no longer be eligible to obtain services from MSU Care. Depending on the severity of
the incident, dismissal may be immediate and termination from the MSU Care may be final.
Any minors (younger than 18 years) who come to the visit with the patient will need to stay with the
patient during the exam and treatment.
INFORMATION DISCLOSURE
As a patient at MSU Care, I will authorize:
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Any health care professional associated with MSU Care to disclose any professional and/or
personal health information to other health care professionals as may be necessary from time
to time in connection with my health care.
Any health administrative team member of MSU Care to disclose my registration and
screening information for the purpose of obtaining no cost or low-cost medications,
laboratory, or other health care services at Mercy or another facility.
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Updated 8/19/2016
CERTIFICATE OF NEED
As a patient of MSU Care, I certify that I have 1) NO health insurance including Medicaid, Medicare,
Catastrophic, or High Deductible Insurance, and 2) meet the MSU Care definition of uninsured and at or below
150% of the Federal Poverty Level.
I also certify that I am honest and accurate about my health insurance and income status to the best of my
knowledge. I understand that not telling the truth about my health insurance status hurts our entire
community, and prevents other patients from being seen in a timely manner.
If my health insurance status changes and I find I am no longer eligible to receive services from MSU Care, I will
either inform MSU Care or discontinue use of the clinic’s services.
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I, the undersigned, have read and understood the information listed above, and comply with the requirements
of this Patient Agreement.
Patient Printed Name
Patient or Legal Guardian Signature
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Updated 8/19/2016
Date
Name: ___________________________________________________
Date of Birth: _________ MR#: __________ CSN#: _____________
Consent and Agreement
Physician Services and Hospital Services
1. Annual Consent for Services: I consent to the services that may be performed by a Mercy Health (“Mercy”)
physician or non-physician provider (“provider”) or facility. I understand I can withdraw this consent at any
time. This consent and agreement applies to any provider services I may obtain from Mercy providers at a clinic
or physician’s office and also to any hospital services I may obtain at a Mercy hospital or from a hospital-based
clinic location.
2. Telehealth Services: I consent to services that may be provided through advanced telecommunications
technology between one site to at least one other site (“telehealth”). I consent to the telehealth services that may
be performed by a Mercy physician or non-physician provider or facility, who may be at a different location
than me. I understand that I can withdraw this consent at any time. I also understand and agree to the
following: (i) I shall have the option to refuse telehealth services at any time without affecting my right to future
care or treatment and without risking the loss or withdrawal of third party payor benefits to which I am entitled;
(ii) I shall be informed of the alternatives to the telehealth services that are available to me; (iii) I shall have
access to the medical information resulting from telehealth services by law; (iv) I consent to the dissemination,
storage, and retention of identifiable images or other information from the telehealth service; (v) I shall have the
right to be advised of the parties who will be present at the originating site and the distant site during the
telehealth services, and I shall have the right to exclude anyone from either site; and (vi) I consent to the
videotaping or other recording of telehealth services, and I understand that I can withdraw this consent at any
time.
3. Financial Agreement: I guarantee and agree to pay for all goods and services provided to me or the patient
named below at the rates listed in Mercy’s Charge Description Master as of the date of treatment, unless I am
entitled to pay a different amount under my (or the patient’s) health insurance plan or my (or the patient’s)
status as a Medicare or Medicaid beneficiary. Should an account be referred to an attorney or collection agency
for collection, I will pay attorney’s fees and collection expenses. Mercy will provide the medical screening
exam to anyone in need of emergency medical treatment, regardless of ability to pay.
4. Assignment of Insurance Benefits: I assign to Mercy, my physician or other non-Mercy healthcare
professionals involved in my (or the patient’s) care my (or the patient’s) rights under all insurance and benefit
plan documents, and authorize direct payment to each healthcare provider of all insurance and plan benefits
payments for services provided to me (or the patient) by these providers. By paying my providers directly, my
insurance company or employer is fulfilling its obligations to me (or the patient) under the health insurance
policy, or the employer is fulfilling its obligations as required by law. I also agree that I (or the patient) am
financially responsible for charges not paid according to this assignment.
5. Medicare Assignment: I certify that the information given by me in applying for payment from any third party
payor, including payment under Title XVIII of the Social Security Act, is correct. I request that payment
Page 1
Name: ___________________________________________________
Date of Birth: _________ MR#: __________ CSN#: _____________
of authorized benefits be made in my (or the patient’s) behalf, and I authorize the Social Security
Administration Office of the Department of Health and Human Services to release information regarding my (or
the patient’s) eligibility for coverage under Medicare Part A and Part B, including but not limited to the
effective date of such coverage. I also authorize Mercy to release to the Social Security Administration or its
intermediaries or carriers any information needed for this or a related Medicare claim.
6. Notice of Privacy Practices: I acknowledge that I have received a copy of the Notice of Privacy Practices
(NOPP), which describes when Mercy may use or disclose information for treatment, payment and health care
operations. The NOPP is considered part of this Consent and Agreement by this reference. I understand that
the NOPP is only provided the first time I receive services from the hospital and is otherwise available upon
request and on Mercy’s website.
7. Monitoring: I understand that monitoring services may be provided through mobile application, medical
device, or other technology. I understand that Mercy facilities may use video monitoring in patient care areas
when there is clinical need and in common areas for security purposes. I consent to such technology and video
monitoring, with the understanding that any images, audio, or data from the monitoring are not readily available
to visitors or the public and will not be disclosed except as required or permitted by law.
8. Legal Relationship between Hospital and Provider: I understand that when I am hospitalized, I am under the
care and supervision of my attending provider, and it is the responsibility of the hospital and nursing staff to
carry out his/her instructions. It is the responsibility of my provider or surgeon to obtain my informed consent,
when required, for specific medical or surgical treatment, special diagnostic or therapeutic procedures, or
hospital services provided to me under the instruction of the provider.
9. Clinic and Hospital Rules: I understand that my visitors and I must obey all Mercy clinic and hospital rules. I
understand that if I or my visitors do not follow the rules, Mercy may pursue corrective action.
10. Personal Valuables: I understand that as a patient, I am encouraged to leave valuable personal items at home.
While Mercy may maintain a safe for small personal items of usual value, Mercy is not responsible for the loss
or damage to these items.
11. Demographic Information: I have reviewed the demographic information listed for me and confirm that it is
correct. I am aware that I need to inform Mercy of any changes as soon as possible.
12. Independent Contractor/Providers: I understand that separate bills may be sent for professional services from
non-Mercy providers such as radiologists, pathologists, and anesthesiologists, in addition to the Mercy bill.
13. Phone Calls: I authorize Mercy and its collection agencies to contact me, or a representative I appoint, about
my account, including using any contact information or cell phone numbers that I have provided or will provide
or that is available to Mercy from third parties. I authorize contact with me by telephone or voice messages and
authorize the use of automated dialing technology and pre-recorded messages, even if I am charged for the call
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Name: __________________________________________________
Date of Birth: _________ MR#: __________ CSN#: _____________
under my phone plan. I agree such contact will not be “unsolicited” for purposes of local, state or federal law. I
agree that Mercy and its collection agencies may monitor and/or record any communication.
14. Notice to Mercy Co-workers: As a co-worker employed by an entity owned or controlled by Mercy, I agree to
payment of outstanding balance(s) due for medical services rendered to me, or any dependence for whom I am
financially responsible, after all applicable insurance payments are received for such services. In the event I do
not make reasonable attempts to resolve the outstanding balances, I understand Mercy may initiate payroll
deduction, in accordance with Mercy’s Co-worker Payroll Deduction Policy.
A copy of this form shall have the same force and effect as the original. The undersigned is the patient or is duly
authorized to act on behalf of the patient to sign for the patient and accept the terms written above. A signed copy of
this form is available upon request.
Signature: _________________________________ Date: ________________ Time: __________________
If signed by other than the patient, indicate relationship: _________________________________________
Witness: __________________________________ Date: ________________ Time: __________________
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Name: ___________________________________________________
Date of Birth: _________ MR#: __________ CSN#: _____________
The Prescription Drug Repository was created by the Missouri Legislature to provide access to unused prescription
drugs for persons who have economic need.
Drugs that have been donated by individual patients may be provided by healthcare facilities such as nursing homes or
hospitals to pharmacies, hospitals or non-profit clinics that agree to dispense the drugs to eligible recipients.
For safety reasons, donated drugs must have been under the control of a healthcare facility or healthcare professional,
and cannot have been in the possession of the individual owner. The owner of the drugs is the patient for whom the
drugs were prescribed and dispensed, regardless of the method of payment.
Participating dispensers may charge recipients a limited handling fee to cover stocking and dispensing costs. This
handling fee may be no more than 200% of the standard Missouri Medicaid dispensing fee. The standard Missouri
Medicaid dispensing fee is $4.09, so repository sites may charge no more than $8.18 per dispensing.
The program went into effect on January 1, 2005.
20 CSR 2220-2.013 Prescription Delivery
Requirements
PURPOSE: This rule establishes requirements for authorized prescription delivery sites
(2) At the request of the patient or the patient’s authorized designee, licensees may deliver a filled prescription for an
individual patient directly to the patient or the patient’s authorized designee or to—
(A) The office of a licensed health care practitioner authorized to prescribe medication in the state of Missouri;
(C) A hospital, office, clinic, or other medical institution that provides health care services;
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Name: ___________________________________________________
Date of Birth: _________ MR#: __________ CSN#: _____________
MSU Care Clinic Medication Donation Form
640 East Cherry Street Suite 105
Springfield, Missouri 65806
417-837-2270
Authorization for Donation of Unused Prescription Medication
I,
, authorize the donation of unused prescription
medication(s) to MSU Care Clinic, a non-profit 501c3 clinic. I understand that in executing this authorization and
donating the unused prescription medication(s), I am consenting to participate in the Missouri Prescription Drug
Repository Program, pursuant to 19 CSR 20-50.025.
I understand that the purpose of donating medication(s) through this program is to provide access to unused
prescription drugs to persons in economic need. I understand that my participation is voluntary, and that my estate, or I
shall not be subject to criminal prosecution, any professional disciplinary action, or as a claim of liability in any civil
action.
I verify that the medication(s) being donated has been in the possession of the MSU Care Clinic licensed health care
professionals as part of a medication patient assistance program, and that I am no longer taking the medication(s). The
medication stored at MSU Care Clinic on behalf of the patient has been stored according to the manufacturer and/or
United States Pharmacopoeia requirements.
Printed Name of Donor:
Signature of Donor:
Date:
Page 5
Form
4506-T
(Rev. September 2015)
Department of the Treasury
Internal Revenue Service
Request for Transcript of Tax Return
Do not sign this form unless all applicable lines have been completed.
▶ Request may be rejected if the form is incomplete or illegible.
▶ For more information about Form 4506-T, visit www.irs.gov/form4506t.
▶
OMB No. 1545-1872
Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using
our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” under “Tools” or call 1-800-908-9946. If you need a copy
of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.
1a Name shown on tax return. If a joint return, enter the name
shown first.
1b First social security number on tax return, individual taxpayer identification
number, or employer identification number (see instructions)
2a If a joint return, enter spouse’s name shown on tax return.
2b Second social security number or individual taxpayer
identification number if joint tax return
3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
4 Previous address shown on the last return filed if different from line 3 (see instructions)
5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address,
and telephone number.
Caution: If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once
you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcript to the third party listed
on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party’s authority to disclose your
transcript information, you can specify this limitation in your written agreement with the third party.
Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form
number per request. ▶
6
a
Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect
changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series,
Form 1065, Form 1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year
and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .
b
Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty
assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability
and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 10 business days .
c
Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account
Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 10 business days
. . . . . .
7
Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available
after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .
8
Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from
these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this
transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For
example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement
purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 10 business days .
Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed
with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.
9
Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four
years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter
each quarter or tax period separately.
/
/
/
/
/
/
/
/
Caution: Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax
information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more
shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I
certify that I have the authority to execute Form 4506-T on behalf of the taxpayer. Note: For transcripts being sent to a third party, this form must be
received within 120 days of the signature date.
Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she
has the authority to sign the Form 4506-T. See instructions.
▲ ▲ ▲
Sign
Here
Signature (see instructions)
Phone number of taxpayer on line
1a or 2a
Date
Title (if line 1a above is a corporation, partnership, estate, or trust)
Spouse’s signature
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
Cat. No. 37667N
Form 4506-T (Rev. 9-2015)
Form 4506-T (Rev. 9-2015)
Page
Section references are to the Internal Revenue Code
unless otherwise noted.
Future Developments
For the latest information about Form 4506-T and its
instructions, go to www.irs.gov/form4506t.
Information about any recent developments affecting
Form 4506-T (such as legislation enacted after we
released it) will be posted on that page.
General Instructions
Caution: Do not sign this form unless all applicable
lines have been completed.
Purpose of form. Use Form 4506-T to request tax
return information. You can also designate (on line 5)
a third party to receive the information. Taxpayers
using a tax year beginning in one calendar year and
ending in the following year (fiscal tax year) must file
Form 4506-T to request a return transcript.
Note: If you are unsure of which type of transcript
you need, request the Record of Account, as it
provides the most detailed information.
Tip. Use Form 4506, Request for Copy of
Tax Return, to request copies of tax returns.
Automated transcript request. You can quickly
request transcripts by using our automated
self-help service tools. Please visit us at IRS.gov and
click on “Get a Tax Transcript...” under “Tools” or
call 1-800-908-9946.
Where to file. Mail or fax Form 4506-T to
the address below for the state you lived in,
or the state your business was in, when that return
was filed. There are two address charts: one for
individual transcripts (Form 1040 series and Form
W-2) and one for all other transcripts.
If you are requesting more than one transcript or
other product and the chart below shows two
different addresses, send your request to the
address based on the address of your most recent
return.
Chart for individual transcripts
(Form 1040 series and Form W-2
and Form 1099)
If you filed an
individual return
and lived in:
Alabama, Kentucky,
Louisiana, Mississippi,
Tennessee, Texas, a
foreign country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana Islands,
the U.S. Virgin Islands, or
A.P.O. or F.P.O. address
Alaska, Arizona, Arkansas,
California, Colorado,
Hawaii, Idaho, Illinois,
Indiana, Iowa, Kansas,
Michigan, Minnesota,
Montana, Nebraska,
Nevada, New Mexico,
North Dakota, Oklahoma,
Oregon, South Dakota,
Utah, Washington,
Wisconsin, Wyoming
Connecticut, Delaware,
District of Columbia,
Florida, Georgia, Maine,
Maryland, Massachusetts,
Missouri, New Hampshire,
New Jersey, New York,
North Carolina, Ohio,
Pennsylvania, Rhode
Island, South Carolina,
Vermont, Virginia, West
Virginia
Mail or fax to:
Internal Revenue Service
RAIVS Team
Stop 6716 AUSC
Austin, TX 73301
512-460-2272
Internal Revenue Service
RAIVS Team
Stop 37106
Fresno, CA 93888
559-456-7227
Internal Revenue Service
RAIVS Team
Stop 6705 P-6
Kansas City, MO 64999
816-292-6102
Chart for all other transcripts
If you lived in
or your business
was in:
Alabama, Alaska,
Arizona, Arkansas,
California, Colorado,
Florida, Hawaii, Idaho,
Iowa, Kansas,
Louisiana, Minnesota,
Mississippi,
Missouri, Montana,
Nebraska, Nevada,
New Mexico,
North Dakota,
Oklahoma, Oregon,
South Dakota, Texas,
Utah, Washington,
Wyoming, a foreign
country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana
Islands, the U.S. Virgin
Islands, or A.P.O. or
F.P.O. address
Connecticut,
Delaware, District of
Columbia, Georgia,
Illinois, Indiana,
Kentucky, Maine,
Maryland,
Massachusetts,
Michigan, New
Hampshire, New
Jersey, New York,
North Carolina,
Ohio, Pennsylvania,
Rhode Island, South
Carolina, Tennessee,
Vermont, Virginia,
West Virginia,
Wisconsin
Mail or fax to:
Internal Revenue Service
RAIVS Team
P.O. Box 9941
Mail Stop 6734
Ogden, UT 84409
801-620-6922
2
Corporations. Generally, Form 4506-T can be
signed by: (1) an officer having legal authority to bind
the corporation, (2) any person designated by the
board of directors or other governing body, or (3)
any officer or employee on written request by any
principal officer and attested to by the secretary or
other officer. A bona fide shareholder of record
owning 1 percent or more of the outstanding stock
of the corporation may submit a Form 4506-T but
must provide documentation to support the
requester's right to receive the information.
Partnerships. Generally, Form 4506-T can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 9.
All others. See section 6103(e) if the taxpayer has
died, is insolvent, is a dissolved corporation, or if a
trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Note: If you are Heir at law, Next of kin, or
Beneficiary you must be able to establish a material
interest in the estate or trust.
Documentation. For entities other than individuals,
you must attach the authorization document. For
example, this could be the letter from the principal
officer authorizing an employee of the corporation or
the letters testamentary authorizing an individual to
act for an estate.
Internal Revenue Service
RAIVS Team
P.O. Box 145500
Stop 2800 F
Cincinnati, OH 45250
859-669-3592
Line 1b. Enter your employer identification number
(EIN) if your request relates to a business return.
Otherwise, enter the first social security number
(SSN) or your individual taxpayer identification
number (ITIN) shown on the return. For example, if
you are requesting Form 1040 that includes
Schedule C (Form 1040), enter your SSN.
Line 3. Enter your current address. If you use a P.O.
box, include it on this line.
Line 4. Enter the address shown on the last return
filed if different from the address entered on line 3.
Signature by a representative. A representative
can sign Form 4506-T for a taxpayer only if the
taxpayer has specifically delegated this authority to
the representative on Form 2848, line 5. The
representative must attach Form 2848 showing the
delegation to Form 4506-T.
Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on this form to establish
your right to gain access to the requested tax
information under the Internal Revenue Code. We
need this information to properly identify the tax
information and respond to your request. You are
not required to request any transcript; if you do
request a transcript, sections 6103 and 6109 and
their regulations require you to provide this
information, including your SSN or EIN. If you do not
provide this information, we may not be able to
process your request. Providing false or fraudulent
information may subject you to penalties.
Routine uses of this information include giving it to
the Department of Justice for civil and criminal
litigation, and cities, states, the District of Columbia,
and U.S. commonwealths and possessions for use
in administering their tax laws. We may also disclose
this information to other countries under a tax treaty,
to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement
and intelligence agencies to combat terrorism.
Line 6. Enter only one tax form number per
request.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form
or its instructions must be retained as long as their
contents may become material in the administration
of any Internal Revenue law. Generally, tax returns
and return information are confidential, as required
by section 6103.
Signature and date. Form 4506-T must be signed
and dated by the taxpayer listed on line 1a or 2a. If
you completed line 5 requesting the information be
sent to a third party, the IRS must receive Form
4506-T within 120 days of the date signed by the
taxpayer or it will be rejected. Ensure that all
applicable lines are completed before signing.
The time needed to complete and file Form
4506-T will vary depending on individual
circumstances. The estimated average time is:
Learning about the law or the form, 10 min.;
Preparing the form, 12 min.; and Copying,
assembling, and sending the form to the IRS,
20 min.
You must check the box in the signature
area to acknowledge you have the
authority to sign and request the
information. The form will not be
CAUTION
processed and returned to you if the
box is unchecked.
If you have comments concerning the accuracy of
these time estimates or suggestions for making
Form 4506-T simpler, we would be happy to hear
from you. You can write to:
Note: If the addresses on lines 3 and 4 are different
and you have not changed your address with the
IRS, file Form 8822, Change of Address. For a
business address, file Form 8822-B, Change of
Address or Responsible Party — Business.
!
▲
Individuals. Transcripts of jointly filed tax returns
may be furnished to either spouse. Only one
signature is required. Sign Form 4506-T exactly as
your name appeared on the original return. If you
changed your name, also sign your current name.
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send the form to this address. Instead, see
Where to file on this page.
COMMUNITY MEDICATION ACCESS PROGRAM (CMAP)
AUTHORIZATION to REPRESENT
I, _____________________________, directly or indirectly through the signature of my legal guardian or representative,
(Print Name)
hereby appoint the Community Medication Access Program (CMAP), its employees and agents to be my Authorized
Representative for obtaining medications.
My Authorized Representative may:
 Execute Patient Assistance program applications on my behalf from the companies that make such medicines if I
am participating in a Patient Assistance Program for such medications.
 Obtain information regarding my medical records, federal/state programs application status, employment
status, income, and assets to substantiate my application(s).
 Pursue the appeal process in the event my application(s) is denied, if appropriate.
 Participate on my behalf and in my absence in any hearing or appeal.
The rights, powers, and authority of my Authorized Representative will remain in full force and effect until the
conclusion of my application(s), when revoked in writing by me or my legal representative or when terminated by my
Authorized Representative. I understand that I must revoke this Authorization to Represent in writing and that
revocation of CMAP as my Authorized Representative is not effective until CMAP or any third party is notified of the
revocation in writing. I attest that the information I have given in this enrollment application is accurate and true. I also
understand that even if my application is approved, provision of medicines is not guaranteed. All applications are
reviewed on a case-by-case basis. A copy of this Authorization to Represent shall have the same force and effect as the
original.
Please note: when requesting assistance for Lantus, Apidra, Lovenox, and/or Multaq, Sanofi Patient Connection and its third party
agents will use your date of birth or social security number and/or additional demographic information as needed to access your
credit information and information derived from public and other sources to estimate your income in conjunction with the
eligibility determination process. As a soft credit inquiry, this option will not impact your credit score.
(Check only one)
 I authorize CMAP program representatives to sign prescription assistance applications on my behalf.
 I do not authorize CMAP program representatives to sign prescription assistance applications on my behalf. I understand this
will delay my receipt of medications by 2-3 weeks, but refusal to allow CMAP representative to sign forms on my behalf has no
impact with respect to my enrollment in this program.
The undersigned certifies that I have reviewed the above provisions, had an opportunity to ask questions and that all of
my questions have been answered to my satisfaction. The undersigned is the patient or is duly authorized to act on
behalf of the patient to execute this Authorization to Represent and accept the terms hereof.
_____________________________________________
Signature of Patient (or Legal Guardian/Representative)
__________________ _____________________
Date of Birth
Date
4520 South National, M.A.P. 1st Floor, Springfield, MO 65810
Phone: (417)820-9290, (877)480-6900 Fax: (417)820-9293
Email: [email protected]
P:\PA Med Man\CMAP – Community Medication Access Program\Patient Communication\Authorization to Represent 2016
COMMUNITY MEDICATION ACCESS PROGRAM (CMAP)
Income Statement
Patient Name: ____________________________________________
Marital Status:
Single
Employment Status: Full-time
Retired
DOB: _________________________
Married
Widowed
Divorced
Part-time
Veteran
Student
Self-Employed
Legally Disabled
Unemployed
Total number of people living in your home: _______; Number of Adults: _______, Number of Children ______
Income
Amount-You
Amount-Others in Household
Wages
Retirement
Social Security
Social Security Disability
Disability
Unemployment
Alimony
Child Support
Investments
Other
TOTAL
Did you file Federal taxes last year?:
Yes – if yes, we need a copy
No
Proof of Income: (please send us a copy of all that apply for each person living in your home)
Complete Federal Tax Return
Unemployment Letter
Child Support Award Letter
Veteran’s Benefits Letter
1099 & W2
Copy of Driver’s License
Food Stamp Award Letter
Social Security Award Letter
Pension/Retirement Earning Statement Social Security Disability Award Letter
4520 South National, M.A.P. 1st Floor, Springfield, MO 65810
Phone: (417)820-9290, (877)480-6900 Fax: (417)820-9293
Email: [email protected]
P:\PA Med Man\CMAP – Community Medication Access Program\Patient Communication\Statement of Support 2016
COMMUNITY MEDICATION ACCESS PROGRAM (CMAP)
Self-Declaration of No Income
Please complete and sign this form if you have claimed zero or no income. Failure to complete this form will
delay the processing of your medications. Leaving the form blank or writing N/A or dashes (---) is not
acceptable.
Patient Name: ____________________________________________
DOB: _________________________
Please explain how you have paid your monthly bills for the past 90 days:
If a non-household member is helping pay your bills, please list the name(s) and phone number(s) below.
First Name
Last Name
Daytime Telephone including Area Code
(
)
(
)
Please explain how you are paying the following monthly expenses:
Bill
Monthly
If paid by
Bill
Amount
someone else,
it is a:
 gift loan
Rent/Mortgage $
Car Payment /
Insurance
 gift loan
Food
$
Cable/Internet
 gift loan
Gas
$
Personal Expenses
 gift loan
Electric
$
Other __________


gift

loan
Phone/Cell
$
Other __________
Monthly
Amount
If pay by
someone else,
it is a:
$
 gift
loan
$
$
$
$
 gift
 gift
 gift
 gift
loan
loan
loan
loan
I certify that the information contained above is true, complete and correct to the best of my knowledge.
Inquiries may be made to verify statements herein. I understand that this agreement will last 1 year, at which
time I will be required to either provide necessary documentation or renew this agreement.
_______________________________________________________________
Patient Signature
________________________
Date
4520 South National, M.A.P. 1st Floor, Springfield, MO 65810
Phone: (417)820-9290, (877)480-6900 Fax: (417)820-9293
Email: [email protected]
P:\PA Med Man\CMAP – Community Medication Access Program\Patient Communication\Statement of Support 2016
PHI Communication Resource Tool
Please print below information
I, _______________________________________________________, hereby authorize release of my Protected Health Information for discussion of
my care or treatment to the person(s) specified below (45CFR, 164.502(F) & 164.502(G):
Authorized family member or person to receive verbal information for the above named patient’s care:
___________________________________________
Name of Central Contact
__________________________________________
__________________________________
Relationship to Patient
Phone
(Other than patient)
Others authorized to receive my verbal information (please list names and relationship):
___________________________________________
Print Name
___________________________________________
Print Name
__________________________________________
__________________________________
Relationship to Patient
Phone
__________________________________________
__________________________________
Relationship to Patient
Phone
♦ Note: This form does not give the above referenced persons permission to make health care decisions for the patient or
entitle them to paper or electronic copies of the patient’s medical record. We will not release via the telephone or any other
means of communication any information to any friends or family members not listed above unless the patient has an
opportunity to object and does not (documented) or if it is reasonable to infer that the patient does not object such as when a
patient brings a spouse into the room when treatment is being discussed. Exception: if the release is needed in emergency
situations.
♦ Do you wish to be a confidential or non-published patient for directory status?
Yes
No
(Example: If you are in our facility seeking treatment and a visitor calls or stops in to see you do you want to remain private and
we will not acknowledge you as a patient? Confidential patients will not receive mail or flowers.)
Yes
No
♦ Leave message on answering machine?
(Example: We may leave message reminders, scheduling changes or notices that lab results are in on your answering machine.
Would this process be acceptable, yes or no?)
Yes
No
♦ Leave message for patient to return call?
(Example: We may leave a message regarding appointment reminders, scheduling changes or notices that lab results are in with
an individual who answers the phone. Would this process be acceptable, yes or no?)
Patient or Legal Personal Representative: _______________________________________ Date: _________________________________
(SIGNATURE)
Patient or Legal Personal Representative: _______________________________________ Relationship to Patient: _________________
(PRINTED NAME)
Note: Except to the extent that action has already been taken in reliance on this PHI Communication Resource Tool, at any time
I can revoke this PHI Communication Resource Tool by submitting a notice in writing to the Privacy Site Coordinator or Privacy
Site Designee.
Patient Name: ________________________________________
MRN #: ______________________________________________
SPR_16168 (1/5/15) 82025
Date of Birth:_________________________________________