Form CMS-10518 Intravenous Immunoglobulin (IVIG) Demonstration Benefici

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

Form Approved
OMB No. 0938-1246

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://med.noridianmedicare.com/web/ivig 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
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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

Form CMS-10518 (7-2014)

( ) Every 3-4 weeks

( ) More than twice a month

( ) Other: ________________

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

I sometimes miss receiving my IV immunoglobulin
medication:
( ) Yes

Note: Do not answer this question if you receive your
medication subcutaneously.
If yes, indicate the reason (Check all that apply):
12b

( ) No

[ ] Cannot afford it

[ ] Not feeling well

[ ] Transportation

[ ] Other: ____________
_____________________

Note: Do not answer this question if you receive your medication intravenously.
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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
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( ) 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-10518 (07/14)

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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

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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.
You may mail your application to this address:
Noridian Healthcare Solutions
IVIG Demo
PO Box 6788
Fargo ND 58108-6788
For overnight delivery, mail your application to:
Noridian Healthcare Solutions
IVIG Demo
900 42nd Street South
Fargo ND 58103
You can fax your completed application to: 701-277-2428
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://med.noridianmedicare.com/web/ivig 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.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1246 (expires 04/30/2018). The time required to complete this information
collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection.If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS
Disclosure: Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact
Jody Blatt ([email protected]).

Form CMS-10518 (07/14)

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