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:
- 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).
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