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IVIG Demonstration Beneficiary Application Completion Guide

In order to participate in the IVIG Demonstration, you must submit a completed application.

You can fill out the application right on the webpage and then print it out to sign and have your doctor sign or you can print out a blank application, fill in the answers, sign it and then have your doctor sign it.

Incomplete applications will be returned to you and will not be reviewed. You will be notified within 10 business days whether or not you have been accepted. Since the number of beneficiaries and funds available for this demonstration are limited, not all beneficiaries who are eligible may be accepted.

Mail your completed application to:

Noridian Healthcare Solutions
IVIG Demo
PO Box 6788
Fargo, ND 58108-6788

Courier Address:

Noridian Healthcare Solutions
IVIG Demo
900 42nd St S
Fargo, ND 58103-2119

Fax your completed application to: 701-277-2428

Section I – Beneficiary Information

Box

Instructions

Box 1

Print your name shown on your Medicare card (Last Name, First Name).

Box 2

Print your date of birth (in MM/DD/YYYY format).

Box 3

Provide your email address if you have one.

Box 4

Print your Medicare number exactly as it is shown on your Medicare card.

Box 5

List the best telephone number where we can reach you if we have questions on your application.

Box 6

Provide your mailing address.

Box 7

Check the appropriate box for gender.

Box 8

Check Yes or No to inform us if you live with a spouse, extended family, or friend.

 

Section II – Medication Information

Box

Instructions

Box 9

List the year (approximate) when you first started receiving your immunoglobulin medication.

Box 10

Check the box that explains how you currently receive your immunoglobulin medication - either intravenously (IV) or subcutaneously (under the skin).

Important Note: The IVIG Demo is specifically for patients who receive (or will be switching to) IV treatment. If you currently receive your medication subcutaneously, you would apply to be part of this IVIG Demo only if you would be changing the method of receiving your medication from subcutaneous to IV.

Box 11

Check the box that describes where you get your IV treatment today.

Note: Skip this and the next question if you currently receive your medication subcutaneously.

Box 11a

Provide the name and address where you receive your IV medication.

Box 12

Check the box that best describes how often you receive your IV medication.

Note: Skip this question if you currently receive your medication subcutaneously.

Box 12a

Check Yes or No to state if you sometimes miss receiving your IV immunoglobulin medication.

Note: Skip this question if you currently receive your medication subcutaneously.

Box 12b

If 12a was Yes, check the box that describes the most common reason(s).

Note: Skip this question if you currently receive your medication subcutaneously.

Box 13

Check this box that best describes how often you receive your subcutaneous medication.

Note: Skip this question if you currently receive your medication by IV.

Box 14

Check all boxes that best describe how this IVIG Demo will help you. If other, please provide details.

 

Section III – Payment Information of IVIG Administration Charges

This section asks questions to understand how you currently pay for the IVIG administration charges (services, supplies and accessories other than the medication itself).

Note: Skip this section if you currently receive this medication subcutaneously.

Box

Instructions

Box 15

Check the box that describes how the administration costs are currently paid.

Box 16

Check the box that describes the insurance or other source of payment that covers the administration costs.

 

Section IV – Beneficiary Signature

Box

Instructions

Box 17

Sign and date the form.

 

Section V – Physician Signature

It is important to talk with your physician about this demonstration, and whether it is appropriate for you to receive IVIG at home. If your physician thinks you are an appropriate candidate for the demonstration, please have him/her provide the requested information and sign the application form.

Your application will not be considered to be complete without your physician's signature.

Box

Instructions

Box 18

Print your physician's name.

Box 19

Provide your physician's telephone number.

Box 20

Ask your physician to fill in their 10 digit NPI (National Provider Identifier).

Box 21

Ask your physician to sign and date the form.

 

Submitting an application for this demonstration does not guarantee that you will be selected to participate.

If you are selected, participation in this demonstration is voluntary and you can withdraw at any time.

Last Updated Sep 27, 2019