How To Apply

You can start the application process for yourself or on someone else's behalf one of two ways:

1. Call 1.866.316.PANF (7263) A dedicated PAN counselor will work with you directly to help you:

• Assess your eligibility for assistance.
• Provide you with an application for assistance.
• Complete your application.
• Answer questions regarding the application process.

2. Start Application Online

Complete a pre-screen online, print and fill out the PDF application provided after the pre-screen, and submit it by mail or fax.

All applications and accompanying materials can be submitted by:

Mail:
Patient Access Network Foundation
P.O. Box 221858
Charlotte, NC 28222-1858

Fax:
1.866.316.7261

Application materials are provided on a patient-by-patient basis. All patients and their physicians will be notified in writing of the eligibility determination upon receipt and review of your completed application.

To be eligible for assistance, you must be a U.S. resident and meet certain financial, insurance, and medical criteria established by the Foundation's board of directors.

All applications must be verified by patients and their physicians and be supported by appropriate documentation including income verification.

Temporary Approval Process
Patients who lack income documentation can be accepted for temporary approval.  Under this process, patients may receive assistance but must submit supporting income documentation to PAN within 30 days to continue to receive PAN help.