Premium assistance verification form

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

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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.