Helping you
receive the
medication
you need
without the
hassle or
expense
Patient Medication Assistance does not handle or ship
any medications.  Each pharmaceutical company must
approve your application before your medications can be
shipped.
( Most cases, annual Income may not exceed $ 19,180 for single
family and $29,500 for patient and spouse)
NO
NO
NO
NO
Please check all medications for proper spelling and dosage
Enroll
Your Full Name:
Your E-mail Address:
Your Phone Number:
Social Security No.
Address:
City, State, Zip Code:
Female
Male
Birth Date:
Gross Monthly Income:
Source of Income:
Did you file Federal
Taxes for 2006?
Monthly Medical
Expenses
YES
YES
Disabled
Marital Status
Number of persons in household
including self:
Are you enrolled in Medicare
If yes, do you have Part D?
No
YES
YES
If yes, Medicare card Number
Private Insurance
YES
Insurance Name:
Policy Number:
Doctor's Name:
Doctor's Phone Number
List All Medications
Strength
Medication
 Dosage
Comments
After you submit your information, we will mail you a personalized welcome packet that
fully explains our service.  The information we mail you is time sensitive.  Please look for
your information packet in the next couple of days.