Direct Member Reimbursement (DMR) Form: Medications and Treatments

From January 2 through January 30, 2026, our phone contact center (866-316-7263) hours are extended to 9:00 am to 7:00 pm ET, Monday through Friday. We are experiencing a higher than usual call volume during this time. You can apply for grants, check your grant balance, check covered medications, renew grants, and manage claims 24/7 through your online portal account at panapply.org.

Patients and caregivers:

You can download and print the PAN Foundation Direct Member Reimbursement form (DMR) to be reimbursed for medications and treatments covered by your grant.

DMR Form PDF – ready to print and fill out by hand

1. Print this form
2. Complete all fields and sign by hand
3. Attach documentation before submitting
4. Instructions to submit the form are included in this download

Fillable DMR Form PDF – type in your information, then print and sign

1. Complete all fields by typing in your information, then save a copy
2. Print the form with your typed-in information
3. Sign the form by hand
4. Attach documentation before submitting
5. Instructions to submit the form are included in this download

Questions?

Contact the PAN Foundation at 866-316-7263, Monday through Friday, 9:00am to 5:30pm Eastern Time