Form CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. xxxx-xxxx

Intravenous Immunoglobulin (IVIG) Demonstration Beneficiary Application
This application is for Medicare beneficiaries that are currently or planning on using intravenous immunoglobulin therapy in
the home. The demonstration will provide a per-visit payment for nursing and supplies needed for the administration of IVIG.
For more guidance on how to complete this application, please see “Enrollment Application Guide”. This document is
available on http://www.medicarenhic.com or by calling 844-625-6284
TYPE OR PRINT INFORMATION

Section I: Beneficiary Information
Name of Beneficiary from Health Insurance Card
(Last)
(First)

Date of Birth (mm/dd/yyyy)
(MI)

2

1

Email Address
3
Medicare Health Insurance Claim (HIC) Identification #

Telephone Number (Include Area Code)

4

5
Mailing Address

Gender
( ) Male

6

8

7

Do you currently live in the same household with a spouse, extended-family or friend?

( ) Female

( ) Yes

( ) No

SECTION II: Medication Information
9

Approximately what year did you start receiving immunoglobulin medication? ______________________________
I receive (or intend to start receiving) the immunoglobulin medication:

10

11

( ) Intravenously (IV) i.e. in your vein

( ) Subcutaneously i.e. under your skin

Note: Do not answer this question if you receive your
medication subcutaneously.

Note: Do not answer this question if you receive your
medication subcutaneously.

I usually receive my IV immunoglobulin at:
(Check all that apply)

Provider Name and Address where you receive your
IV immunoglobulin medication:

[ ] Home

11a

[ ] Doctor’s office

[ ] Outpatient Hospital Department/Infusion Center

___________________________________________
___________________________________________
___________________________________________
___________________________________________

Note: Do not answer this question if you receive your medication subcutaneously.
12

I currently receive (or am scheduled to receive) my intravenous immunoglobulin medication:
( ) Twice a month

( ) Every 3-4 weeks

Form CMS-xxxxxx (xx/xx) XX xx/xxxx

( ) More than twice a month

( ) Other: ________________

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

12a

Form Approved
OMB No. xxxx-xxxx

Note: Do not answer this question if you receive your
medication subcutaneously.

Note: Do not answer this question if you receive your
medication subcutaneously.

I sometimes miss receiving my IV immunoglobulin
medication:

If yes, indicate the reason (Check all that apply):

( ) Yes

12b

( ) No

[ ] Cannot afford it

[ ] Not feeling well

[ ] Transportation

[ ] Other: ____________
_____________________

Note: Do not answer this question if you receive your medication intravenously.
13

I currently receive my subcutaneous immunoglobulin medication:
( ) Weekly

( ) Twice Weekly

( ) Other: ________________________________________

My participation in this Medicare demonstration will (Check all that apply):
[ ] Reduce the time spent traveling to and from, and at the provider’s office/hospital for intravenous administration
[ ] Reduce my absence from daily activities
[ ] Reduce my out of pocket payments for receiving the medication intravenously
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[ ] Reduce exposure to infection
[ ] Reduce the risk of impaired driving attributed to reaction to infusion
[ ] Improve my overall quality of life
[ ] Other: ________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

SECTION III: Payment Information of IVIG Administration Charges
This section asks questions to understand how you
currently pay for the IVIG administration charges
(nursing and supplies other than the medication itself).

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

Who currently pays for the cost of nursing and supplies associated with this drug (not the cost of the drug itself)? If
you are currently not taking this medication but plan to, who do you expect will pay for these expenses if you do not
participate in the demonstration (Check one):
( ) I pay for it all
15

( ) I pay for most of it , but some costs have been covered through insurance or a drug assistance plan
( ) Most of the costs are paid by insurance or a drug assistance plan
( ) I receive the drug at a physician/hospital department/outpatient infusion center; and do not pay any cost
( ) I don’t know
Check the other health insurance that covers the nursing and supplies associated with this drug. If you are currently
not taking this medication but plan to, check the other health insurance that will cover the nursing and supplies
associated with this drug if you do not participate in the demonstration (Check all that apply):

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[ ] Medicaid

[ ] Veteran’s benefit

[ ] Retiree/spouse’s employer health plan

[ ] Privately-purchased policy (not Medi-gap)

[ ] State or county program other than Medicaid

[ ] Pharmacy company program

[ ] I don’t know

[ ] TRICARE

[ ] None

[ ] Other: _______________________________

Form CMS-xxxxxx (xx/xx) XX xx/xxxx

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. xxxx-xxxx

SECTION IV: Beneficiary Signature
I understand that application to participate in this demonstration does not guarantee that I will be selected to
participate and that, if selected, participation in this demonstration is voluntary and I can withdraw at any time.
Beneficiary Signature

Date

17

SECTION V: Physician Signature
Physician Name (Printed)
18
Physician Phone number
19

Individual NPI
20

I attest that I am treating this patient, that the patient has primary immune deficiency disease, and is a candidate for home IVIG.
Physician Signature

Date

21

If you wish to participate, you must complete, sign and submit an application, as space and funding for this demonstration are
limited. Both you and your physician must sign the application, and we must receive it no later than 5 p.m. Eastern time,
xx/xx/xx for this initial enrollment period.
You may mail your application to this address:
NHIC, Corp.
IVIG Demo
P.O. Box 9140
Hingham, MA. 02043-9140
For overnight delivery, mail your application to:
NHIC, Corp.
IVIG Demo
75 Sgt. William Terry Dr.
Hingham, MA. 02043
You can fax your completed application to:
781-741-3533
If there’s space available after the initial enrollment period, we will accept and review applications as they come in until we fill
all slots.
Submitting an application for this demonstration doesn’t guarantee that we will select you to participate.
For helpful IVIG Demonstration information and guidance on how to complete this application,
visit http://www.medicarenhic.com and see the “Enrollment Application Guide”.
Call the IVIG Demonstration at 844-625-6284 for help with the form, or with questions about the IVIG Demonstration.

Form CMS-xxxxxx (xx/xx) XX xx/xxxx

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