Helping you
receive the
medication
you need
without the
hassle or
expense
Payment Options
Save time and money by paying your first months
payment now. By enrolling today, we will process
your application within 24 hours and mail you all the
completed information necessary for assistance.
Please complete the information below.
Your name as appears on check Name of Bank
Bank Routing Number Bank Account Number
Bank account number is
located after routing number
Routing Number is located on
the bottom Left of check
Please insert check number here
By clicking submit, I authorize Patient Medication Assistance Inc. to deduct
$32.00 from my checking account. I understand this is only one time, and I
will be billed each month for my service fee. I also understand I may cancel
at anytime with a 30 day written notice.
Important notice- Please put a X here if you have Medicare
part D. You will be charged $59.00 for annual enrollment.
If you do not want to pay now and would
like to down load an application or pay
later, please click here.
If you want
to
pay later,
please click
here.
