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Blondell Rx NY LLC d/b/a Quick Rx Specialty Pharmacy (the “Pharmacy”) abides by its legal and third party payor contractual obligations to collect patient cost-sharing amounts. Recognizing that circumstances may arise where an individual is unable to pay their cost-sharing responsibility, we have adopted a policy of screening requests for cost-sharing financial hardship waivers. To do this, we must ask for certain financial information. All information will be held confidential according to our privacy policy. Please note that all actual requests for a cost-sharing waiver are to be considered on an individualized basis. If and once a waiver has been granted, you may be asked to sign a receipt in each instance that the Pharmacy dispenses medication to you, confirming that your cost-sharing obligation has been waived based upon the information provided in and with this application, and that the information remains true at the time of each instance where medication was dispensed. To the extent that your financial situation changes and a waiver is no longer necessary, you are asked to inform the Pharmacy of such occurrence. This application is valid for a period of one year, at which point a new application, if necessary, must be submitted and reviewed.