Patient Assistance programs for your patients
Patient Medication Assistance can help your patients receive the medications they need without the hassle usually associated with patient
assistance programs. We complete all necessary pharmaceutical applications that your patient may need for drug assistance. Our
applications are computer generated and only require the patient and physician's signature. We save you the hassle and expense of
completing patient assistance applications, tracking and renewing medications.
Let us show you how hundreds of doctors and clinics help their patients receive free or low cost medications and let us do all of the work.
Our program is designed to help individuals with low income and no prescription coverage. We also help individuals with Medicare Part
D that have reached their cap or doughnut hole.
Program Features:
• Match your patient’s prescriptions with the correct pharmaceutical company.
• Mail your patient completed applications that only require signatures.
• Keep a current data base with over 2,000 available medications.
• Check all applications for accuracy before sending to the pharmaceutical companies.
• Over 99% of our applications are approved the first time.
• Track and renew medications for quick refills.
• Personal service M-F 9:00 a.m. to 5:00 p.m.
Program Fees:
Patient Medication Assistance bills your patient $32.00 monthly. We make the entire process easy for the patient and physician by
providing completed computer generated patient assistance applications, tracking and renewing medications for quick refills. We also
provide complete management of multiply assistance programs and full customer support with a toll free number. No long term contracts,
your patient may cancel at any time with a 30 day notice.
Patient Medication Assistance is dedicated to making the process for patient assistance programs easy to understand and less time
consuming. Please hand out our applications to all patients that need help with their medications. If you have questions about our service,
please call our customer care department at 1-866-353-9377
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Paying for prescription drugs can be very costly, especially if you have no insurance or make little money to pay for expensive medication.
Patient Medication Assistance will locate free medication for you. Hundreds of Pharmaceutical companies give out free medications under
patient assistance programs. Most pharmaceutical companies do not advertise or widely promote these programs. Patient Medication
Assistance will help determine your eligibility for the patient assistance programs and assist you with completing the proper paperwork
required by each pharmaceutical company.
Each pharmaceutical company has its own requirements. In most cases to be eligible for free medication applicants must show that:
* You do not have prescription drug coverage
* Your income is low enough that paying for prescription drugs is very difficult
* Approximate income for individuals $19,000 or less 2 people in household $30,000 or less.
* You do not qualify for Medicaid or other government assistance programs
Program Features:
* Mail you completed pharmaceutical applications that only require signatures.
* Check your forms for completeness and eliminate any unnecessary paper work.
* Keep track of any changing eligibility requirements.
* Keep a current data base of almost 200 pharmaceutical companies.
* Personal service M-F 9:00 a.m. to 5:00 p.m.
How it works
1) Please complete your Patient Information and Medication forms and return with your first month’s payment in provided envelope. Also
choose delivery option.
2) Once we receive your information, we will mail you completed pharmaceutical applications for your signature and review.
3) Sign all applications and return in postage provide envelope.
4) We work closely with your doctor’s office to have their portion completed.
5) Patient Medication Assistance will review your pharmaceutical application for accuracy, and then forward all applications to the
appropriate pharmaceutical company.
6) After the pharmaceutical companies approve and process your application, you should expect to start receiving your medications in 2 to
4 weeks.
7) Patient Medication Assistance will track your medications for renewal and complete all applications needed to reapply for your
medications.
Quick Application
Full Name______________________________________________________________
Please print
Complete mailing address__________________________________________________
City_______________________ State____________ Zip Code___________
Home Phone(________)_________________Cell/Work(______)___________________
Area code Number Area Code Number
Social Security Number_____________________ Date of Birth___________________
Male Female Married Single Divorced Widow
Are you Disabled? Yes No Did you file taxes for 2007? Yes No
How many people live in your household? ____________________________________
Do you have prescription drug coverage? Yes No If yes please explain next page.
Are you enrolled in Medicare? Yes No Medicare Part D? Yes No
What is your total monthly income for your entire household? ____________________
Please list all sources of income______________________________________________________
Example: Social Security, Wages, Pension, Disability etc.
Please list all medications on next page.
By signing below I understand that: 1) Each pharmaceutical company must approve my application and some medications may not be
available. 2) I will receive a full refund if I do not qualify for drug assistance. 3) A 30 day writen notice is required to cancel service. 4) Most
medications are shipped in a 90 day supply. 5) I am not paying for pharmaceutical applications and most can be obtained for free. 6)
Patient Medication Assistance does not handle or ship medications and are not affiliated with any pharmaceutical companies. 6) If I run
out of medications I should purchase my medication while waiting for drug assistance. 7) I am paying Patient Medication Assistance
$32.00 per month to complete patient assistance applications, track and renew my medications.
Please include your first months payment of $32.00 and mail to:
Patient Medication Assistance
8103 East US Hwy 36 Suite #245
Avon, IN 46123
1-866-353-9377
_____________________________________ _______________
Signature Date
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PATIENT MEDICATION FORM
Name of Medication Strength Quanity Per Day Doctor's Name Doctor's Phone Number
EXAMPLE Synthroid 40 mg 2 Joe Jones (317) 123-4567
1
2
3
4
5
6
7
8
9
10
Comments or additional medications
Please print correct spelling of medication and do not send prescriptions with application.
Please enclose a check for $32.00 with completed application to
Patient Medication Assistance
8103 East US Hwy 36 #245
Avon, IN 46123
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Patient Medication Assistance charges for the administrative service of managing and tracking prescription medications received with our
assistance. The medications themselves are free from the pharmaceutical companies. We keep a data base with more than 200
pharmaceutical companies that offer free medications, however Xubex and RX Outreach charge small co-pays or delivery charge. (Between
$20 and $30 for a 90 day supply)
Monthly Service Fee
We charge a $32.00 monthly service fee to manage your patient assistance programs. We will also work with your doctor’s office and
pharmaceutical companies to help ensure fast and accurate refills of your medications.
We bill our clients $32.00 monthly regardless of the number of medications. Your service is pre-paid each month and you may cancel at
any time with a 30 day written notice.
Example:
In January you begin receiving 5 medications (you pay $32.00 per month)
In February you add additional medication (you still pay only $32.00 per month)
We bill all of our clients monthly; you should receive your first statement in 30 to 45 days.
Money Back Guarantee
We do not accept all applications. If we feel based on the information you provide, that you will not qualify for assistance, you will receive a
full refund within 10 business days.
Over 95% of the applications we send to the pharmaceutical companies are approved. If for any reason you are denied assistance for all of
your medications, we will refund all service fees paid within 10 business days of notification.
Customer Service
Once we receive your completed application, you will be assigned a customer care representative. Your representative will complete all
necessary applications and work closely with your doctor’s office. Your representative is available to assist you Monday –Friday 9:00 a.m.
to 5:00 p.m. (Eastern Standard Time)