Would you like to apply on behalf of a patient?

Providers, case managers, caregivers and patient advocates can apply on behalf of a patient. Applications can be received online or by telephone, electronic document upload, fax, or mail. In doing so, it is necessary to obtain the following information:

  • Basic Patient Info, including:
    • Name
    • U.S. Address
    • Phone number
    • Date of birth
    • US Citizenship or Residency
  • Patient insurance and prescription info
  • Patient income information (household size and household income).

If the patient meets initial program eligibility, conditional approval may be granted. Conditional approval gives patients 30 days of immediate assistance for open programs where funding is available. To receive assistance past the 30-day period, patients need to submit a completed application, including their signature and agreement to the program terms and conditions within the conditional period.


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4 years ago

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