All information obtained during this screening is true and complete in all respects. Patients will promptly notify FSCDR if any information provided changes, including income level or medical condition. The prevention of fraud is of utmost importance to FSCDR. FSCDR has the right to verify the accuracy of information provided during screening and patient’s ongoing program eligibility. Detection of fraud or abuse will result in the application not being eligible to receive assistance from any FSCDR Financial Assistance program in the future. FSCDR, its employees and agents are authorized to obtain and discuss medical, treatment, therapy, financial, and other information relating to the patient with their health care providers and their staff, pharmacy, employer, insurance company, and any other person or entity working on the patients behalf to confirm eligibility. FSCDR will verify a patient’s identity through an instant verification system. The use of their name and social security number to access credit information is to confirm the identity of the applicant and does not affect their credit score. If the identity of the applicant cannot be verified by instant verification service, FSCDR will require additional documentation. Neither FSCDR nor any of its employees or agents will disclose any patient individually identifiable information to any third party except as provided above, as required by law, as deemed appropriate by FSCDR to resolve any potential fraud or audit irregularity, or as necessary or appropriate for FSCDR to provide assistance to patient under the program. FSCDR may use information and data relative to patient to develop aggregate reports as FSCDR seems appropriate. The COVID-19 Patient Financial Aid Program continuation is dependent on the availability of funds and the program can be modified or discontinued at any time if funding is limited or no longer available.

The applicant’s attestation and responses will be recorded and kept on file.