I verify that the information provided in the application is complete and accurate. I further understand that I may be asked to provide proof of the reported financial information on the application if asked by the SOC FUND. I verify that I have provided the information for payment/pending payment for financial assistance from sources other than the SOC FUND.
I recognize that the SOC Fund is providing full or partial financial assistance for the service described in this application as deemed medically necessary by my healthcare provider (s). SOC Fund is in no way liable for the success/failure of this service or for any harm to my health that it may cause. I authorize the SOC Fund and its agents to obtain and discuss information related to the application process with my prescribing physician, pharmacy, employer, insurance company, or other organizations working on my behalf of obtaining services. The SOC Fund and/or its agents or authorized designee agrees not to disclose any individually identifiable information to any third party, except as provided herein or except as required by law. The SOC Fund can, however, use the data to develop aggregate reports as directed by its Board of Directors.
I understand that the SOC Fund reserves the right at any time and without notice to modify or discontinue any or all of the programs with respect to any applicant or in their entirety, to modify the related eligibility criteria, or to terminate assistance at any time.
Thank you! Your request has been sent for review.
****** FOR SOC-FUND USE ONLY******
Patient Notified YES NO Comment: