Direct Member Reimbursement (DMR) Form: Medications and Treatments
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 copay grant.
Do not use this form to request reimbursement for travel or insurance premiums. For these, please complete this form and upload your documentation: secure upload form.
DMR Form PDF
You can print this form and complete it by hand, or use your PDF reader app to fill it out before you print and sign it. Instructions to submit the form are included in this download.
Please remember to:
- Sign before submitting
- Attach documentation before submitting
Questions?
Contact the PAN Foundation at 866-316-7263, Monday through Friday, 9:00am to 5:30pm Eastern Time