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Clozaril/Clozapine Program
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Clozaril/Clozapine Program
About the Program
About Clozaril/Clozapine
About The Athelas Home Device
Application for Clozaril Program
Frequently Asked Questions
Make Payment
General Info
About Us
Contact Us
Shipping Map
HIPAA Privacy Policy
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Golden Gate Pharmacy Services Inc
Services
Independent Patient
Institutional Facilities
Clozaril/Clozapine Program
Portal Access
COVID-19
COVID-19 Vaccinations
COVID 19- Oral Treatments
Clozaril/Clozapine Program
About the Program
About Clozaril/Clozapine
About The Athelas Home Device
Application for Clozaril Program
Frequently Asked Questions
Make Payment
General Info
About Us
Contact Us
Shipping Map
HIPAA Privacy Policy
English
English
Spanish
Your Health Simply Delivered
Application for Clozaril Program
Please complete the following fields accurately and completely if you would like Golden Gate Pharmacy to determine if you are eligible for our program. Any blank or incorrect information may cause a delay.
Step
1
of
13
7%
I am Currently
(Required)
I am currently taking Brand name Clozaril
I am currently taking Generic Clozapine
I am currently taking Orally Disintegrating Clozapine (Fazaclo ODT)
I am currently taking Versacloz (liquid clozapine)
I am not taking any of the above
My total Daily dose is:
(Required)
My Lab Frequence is:
(Required)
Weekly
Biweekly
Monthly
Personal Information
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Female
Male
Prefer not to say
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Is this your shipping address?
(Required)
Yes
No
Shipping Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Insurance Information
Insurance Type
(Required)
Commercial/Private
Medicare
Medicaid
Other
Insurance Company
(Required)
ID
(Required)
Group #
(Required)
PCN #
(Required)
BIN #
(Required)
Phone
(Required)
Picture of Card Front
Max. file size: 32 MB.
Picture of Card Back
Max. file size: 32 MB.
Do you have other Insurance to Add?
(Required)
Yes
No
Insurance Information #2
Insurance Type
(Required)
Commercial/Private
Medicare
Medicaid
Other
Insurance Company
(Required)
ID
(Required)
Group #
(Required)
PCN #
(Required)
BIN #
(Required)
Phone
(Required)
Picture of Card Front
Max. file size: 32 MB.
Picture of Card Back
Max. file size: 32 MB.
Do you have other Insurance to Add?
(Required)
Yes
No
Insurance Information #3
Insurance Type
(Required)
Commercial/Private
Medicare
Medicaid
Other
Insurance Company
(Required)
ID
(Required)
Group #
(Required)
PCN #
(Required)
BIN #
(Required)
Phone
(Required)
Picture of Card Front
Max. file size: 32 MB.
Picture of Card Back
Max. file size: 32 MB.
Doctor Information
Doctor Name
(Required)
First
Last
Doctor Phone
(Required)
Pharmacy Information
Pharmacy
(Required)
Phone
(Required)
If Eligible
(Required)
If eligible, I would like Golden Gate Pharmacy Services to fill all my medications including Clozapine/Clozaril
If eligible, I would like Golden Gate Pharmacy Services to fill ONLY Clozapine/Clozaril
If you have a list of your medication, please upload it here:
Max. file size: 32 MB.
If you do not have a list, please type in your medications below:
Known Allergies:
(Required)
YES
NO
If is Yes, List them here
(Required)
Athelas
I am interested in getting information about the Athelas Home finger stick blood testing device
(Required)
Athelas Home
YES
NO
If Applicable Only:
Name of Care Agency
Case Manager Name
Case Manager Phone
Printed name of individual filling out form
(Required)
Relationship
(Required)
Self
Parent/Guardian
Other
Specify relationship
(Required)
HIPPA
Do you already have an authorization from to release protected health information (PHI) to Golden Gate Pharmacy Services?
(Required)
YES
NO
Please Upload File
(Required)
Drop files here or
Select files
Max. file size: 32 MB.
Re: Patient Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
to: Name of Representative
(Required)
First
Last
Representative Capacity
(Required)
(Family member, advocate, Power of Attorney etc)
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
II. Effective Period
(Required)
This authorization shall be in force and effect until (date or event), at which time this authorization expires.
All past, present, and future periods.
Effective until
(Required)
MM slash DD slash YYYY
III. Extent of Authorization
(Required)
I authorize the release of my complete health record (including records relating to mental healthcare, and treatment of alcohol or drug abuse).
I authorize the release of my complete health record with the exception of the following
information:
(Required)
Mental health records
Alcohol/drug abuse treatment
Other
Other (please specify):
(Required)
Signature of patient or Personal Representative
(Required)
Reset signature
Signature locked. Reset to sign again
Date
(Required)
MM slash DD slash YYYY
Printed Name of Person Signing
(Required)
First
Last
If signed by the patient’s representative, explain your authority to act on behalf of the patient:
(Required)
Acknowledgements
Automatic Refill Program
(Required)
I have read and acknowledged Golden Gate Pharmacy Services Automatic Refill Program.
Automatic Refill Program.
(Required)
Packaging
(Required)
I acknowledge that the standard packaging options are non-childproof. Please contact our pharmacy for childproof solutions.
(Required)
Branded medication
(Required)
I am requesting Golden Gate Pharmacy to fill Clozaril Branded medication for my prescriptions.
(Required)
Test Claim
(Required)
I understand Golden Gate Pharmacy Services will submit a test claim on my behalf to determine eligibility for this Program
(Required)
Term of Services
(Required)
I agree to Golden Gate Pharmacy Services Terms of Services.
Terms of Services.
(Required)
Athelas
(Required)
I authorize Golden Gate Pharmacy Services to share HIPAA Information with Athelas
(Required)
HIPAA
(Required)
I have read and acknowledged Golden Gate Pharmacy Services HIPAA Privacy Policy.
HIPAA Privacy Policy
(Required)
Signature
(Required)
Reset signature
Signature locked. Reset to sign again
How did you hear about this program?
(Required)
A friend, family or coworker
A healthcare professional
LinkedIn
Social media (Facebook, Instagram)
Blog or publication
Golden Gate Pharmacy
Athelas
CAPTCHA