Premium assistance verification form

Premium Verification

1Patient Identification

2Premium Verification

3Terms & Conditions

Are you a patient?(Required)

Yes

What is your relationship to the patient?(Required)

I'm a family member or caregiver

I work in a healthcare provider's office

I work in a pharmacy

Other

First name(Required)

Last name(Required)

Email address(Required)

Phone number(Required)

Fill out the following information so we can verify your patient's identity:

Patient's first name(Required)

Patient's last name(Required)

Patient's email address(Required)

Patient's phone number(Required)

Date of birth(Required)

Patient PAN member ID

Does this all look correct?

Please provide us more information about your insurance below

Insurance name(Required)

Insurance member ID

Are you the policy holder?(Required)

Yes

Number of dependents(Required)

Premium amount:

Premium term(Required)

Premium amount(Required)

Select the document(s) that you are submitting from the following:

Insurance card

Social Security Administration benefit verification letter

Paystub(s) for one whole month

Insurance statement

COBRA coupons

Insurance statement / bill from educational institutions

Other

Review and consent to our terms & conditions

Read this carefully before you submit your reported premium insurance information through the form. By submitting information to the PAN Foundation and clicking “I agree,” you’re confirming that you have read, understand, and agree to the PAN Foundation’s terms and conditions as follows:

You attest and certify under penalty of law that the reported premium insurance information is complete and accurate.
You acknowledge and understand that any false or incomplete information that you provide in your application or through this form could harm the PAN Foundation, including its reputation and tax-exemption status. It could also constitute fraud for which you may be legally liable.
You acknowledge and understand that if the PAN Foundation provides you with assistance and then becomes aware of any inaccurate information or fraudulent activity related to your application or the provided assistance, PAN will terminate your grant and may recoup the provided amount.

Terms and Conditions(Required)

I agree

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