Change Doctor Form

I have switched doctors for my medication(s)

This doctor is now prescribing the following medication(s):

I acknowledge that by submitting this Request, I agree to have The Rx Helper and its affiliates provide the services for the sole purpose in obtaining assistance for my prescription medication(s). I also confirm that the information provided in this application is true and correct to the best of my knowledge. I agree that this release of information will remain in effect until termination of my assistance with The Rx Helper. I understand that I have a right to revoke this authorization by providing written notice to The Rx Helper. However, this authorization may not be revoked if The Rx Helper, its employees or advocates have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. We are not affiliated with the pharmaceutical companies, nor can we guarantee your acceptance into the PAP programs. Your approval will ultimately come from the pharmaceutical company that makes your medication. The employees working with The Rx Helper are not licensed physicians or pharmacists. We are advocates that help to facilitate the completion of the PAP forms and applications. We cannot increase or decrease dosages, prescribe medication. The responsibility to taking the correct medication as prescribed by your physician will fall to you, the patient. All text, images and other content of this website and materials are protected by copyright law and shall not be used, adapted or reproduced in any medium without the express, specific written consent of owner.