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).

Authored by:


3 years ago

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