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Application Instructions

Patients applying for financial assistance for their copayments need to have access to the following information:

Step 1

You will need to select the disease, for which you are seeking assistance, insurance type, and medication. If you are commercially insured, and have selected a medication, for which the manufacturer program has a co-pay card program, you will be made aware under the alternative programs box. Please check it out as manufacturer programs may be more generous than what PAN has to offer.

Step 2

You will need to select the use type. If you are the patient, then click the box "I am applying for myself". If you are an advocate, then click the "I am applying for someone else" box. If you are a specialty pharmacy, you will need to undergo the training with PAN Foundation.

Step 3

You will need to access to the following information for the patient:

Demographic information:
  • First name
  • Last name
  • Social Security Number or Alien Number
  • Date of Birth
  • Gender
  • Marital Status
  • Employment Status
  • Phone number
  • E-mail address
  • Address
  • Language the patient speaks and understands
  • Residency status

  • Income Information:
  • Number of people in the household
  • If you or anyone in your household is employed, how much income was received by wages, tips, or salaries? (If you file a tax return, this information can be found on line 7 of the 1040 form or line 1 of the 1040 EZ form. You may also find this information on a W-2 form).
  • If you or anyone in your household receive income from IRA distributions, pensions, or annuities, how much did you receive? (If you file a tax return, this information can be found on line 15a or 16a of 1040 form. You may also find this information on a 1099 form).
  • If you or anyone in your household receive Social Security Benefits, what was the amount of the benefits received? (If you file a tax return, this information can be found on line 20a of 1040 form. You may also find this information on the 1099 or the Award letter provided annually by the Social Security Administration).
  • Do you receive any other income (child support, alimony, rental income, etc.)?
  • Is this income reflective of your current income?

  • Insurance/Co-payment Information
  • Primary Insurance Carrier:
  • Policy ID Number
  • Group Number
  • Telephone Number

  • You will have the option to enter secondary insurance carrier

  • What is your co-pay or coinsurance for your "name of the disease fund" medications?
  • Do you receive assistance from any other co-pay or coinsurance assistance organizations?
  • How did you first hear about Patient Access Network?

  • Step 4

    Physician Information
  • First Name
  • Last Name
  • Phone Number
  • Fax Number
  • Email
  • Address

  • Step 5

    Please review your application to make sure the information entered is correct and then submit your application online.