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(This Information Will Determine Your Eligibility for Qualifying for PAP Assistance)
Please specify each amount you are receiving. If you have a spouse, their income is needed as well. You must be able to provide documentation of this income to qualify.
(If more than three doctors, please attach a separate sheet with additional information)
Please list all medications needing assistance.Make sure to have correct spelling of your medication. Your prescription bottles will provide you with access to all the information needed to fill out this section. Each medication needs to meet certain qualifications. Not all medications have PAP Assistance Programs.
Medication (Please start with most expensive medications first)
(If more than nine medications, please attach separate sheet with additional information)
I agree to have Patient Help Programs 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 'Patient Help Programs'. I understand that I have a right to revoke this authorization by providing written notice to 'Patient Help Programs'. However, this authorization may not be revoked if 'Patient Help Programs', 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.
I authorize the release of information including the diagnosis, records, examination rendered to me and prescription assistance information. This information may also be released to:
Information is not to be released to anyone.
We hold various promotions throughout the year for referrals brought to us by our current patients, doctors' offices, insurance broker's, advocacy groups, etc. If you were referred to our program by someone who has already afforded the benefits of our service please enter their Rx Helper Patient ID Number and /or name below.