Enrollment Form for Prescription Assistance

Patient Info

Best Time to Call

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Insurance Info

Do you have prescription drug coverage? (This does not include discount cards/programs)
YesNo

Do you have a Medicare Part D Plan?
YesNo

If yes, Company Name is

Financial Info

(This Information Will Determine Your Eligibility for Qualifying for PAP Assistance)

Did you file a Tax Return last year?
YesNo

If yes, the TOTAL income on last return $

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.

Wages
YesNo
Monthly Total

Patient

Spouse

Social Security
YesNo
Monthly Total

Patient

Spouse

Disability
YesNo
Monthly Total

Patient

Spouse

Pension
YesNo
Monthly Total

Patient

Spouse

Unemployment
YesNo
Monthly Total

Patient

Spouse

Other
YesNo
Monthly Total

Patient

Spouse

Total Amount

Patient

Spouse

*Total Number of People in Household

*Total Household Income

If you have no income, please explain

If your income is lower than last year’s Tax Return, please explain

DOCTORS INFO

(If more than three doctors, please attach a separate sheet with additional information)

Applicant

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)

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Hipaa Release

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:

Spouse

Child(ren)

Other

Information is not to be released to anyone.

Message
Please Call

Home

Work

Cell Number

If unable to reach me

You may leave a detailed message

Please leave a message asking me to return your call

The best time to reach me is

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Name of Applicant:

Date:

Were you referred to our program by someone you know?

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.

Referrals Patient ID Number and/or Referral's Name:

I acknowledge that by submitting this Request for Assistance, I am expressly authorizing to be contacted via telephone at the number provided above. We are not affiliated with the pharmaceutical company's, 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 our company 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 mediation 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.