Patient Assistance Program
Patient (or Legal Guardian) Instructions

Gross Monthly Household Income: Please include your total GROSS MONTHLY HOUSEHOLD income. If that income comes from salary/wages/dividends, social security, social security supplemental income, disability, unemployment compensation, pension/annuity, alimony/child support, rental income or other (please specify), indicate the dollar amount. Once complete, a fax cover sheet will appear. Please print and fax along with most current W-2 forms or other proof of income. If there is NO household income, please submit a letter with the application.

All information contained in this application will only be used for
the purpose of evaluating the patient’s application for eligibility.

This section to be completed by Patient or Legal Guardian
Patient First Name: 
Patient Last Name: 
Street Address 1: 
Street Address 2: 
City:    State:   Zip Code: 
Ph. #:  Fax #: 
Birth date:  / / Social Security #:
Medicare ID #:  Alien Reg. #: 
Gross Monthly Household Income of Applicant (Please attach most current documentation):
Salary/Wages/Dividends
  $ .00
Pension/Annuity
  $ .00
Social Security
  $ .00
Alimony/Child Support
  $ .00
Disability
  $ .00
Other:
  $ .00
Unemployed Compensation
  $ .00
TOTAL/MONTH
  $ .00
U.S. Resident
 Sex:
Number of persons DEPENDENT upon primary income within family: 
Are you currently enrolled in Medicare Part D?

If enrolled in Medicare Part D, please provide a copy of the front and back of your Medicare Part D card.
Do you currently have prescription drug coverage other than Medicare Part D?

By clicking the box below, I hereby certify that the above information is correct and complete. I authorize UCB, Inc. and its agents to review the medical and financial information provided. I also authorize UCB, Inc. to contact my prescribing physician, pharmacy or insurance company to discuss this application, and any information about me that may be related to this application. I understand that this product is being provided free of charge outside of Medicare, Medicaid, or any public or private third party. I certify that I will not submit any claims for reimbursement or credit for product received to Medicare, Medicaid, or any third party payer. I understand UCB, Inc. has the right to revise, change, or terminate the UCB Patient Assistance Program at any time.
I agree.





This section to be completed by the Attending Physician

Please select one of the following drug strengths.
Attach your prescription to this form.

*Vimpat Maximum Daily Dosage = 400mg
Physician's First Name: 
Physician's Last Name: 
DEA#:  DEA# Expiration:  / /
State License #:  State:
Expiration Date:  / / Ph. #: 
Street Address 1: 
Street Address 2: 
Street Address 3: 
City:    State:   Zip Code: 

Diagnosis and/or Diagnostic Code(s):



Call 1-866-395-8366 if you have questions or need assistance.
UCB, Inc. reserves the right to change the provisions of this program at any time
Vimpat® is a registered trademark under license from Harris FRC Corporation

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