Sample Claim Form - PAN Foundation
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We can’t always pay back the people who’ve helped us, but we can always pay it forward. Help reach the goal of 500 participants by March 31!

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Donate
  • Apply and manage grants  

    How to apply, manage a grant, file claims and reimbursements, and details about our grants

    • Our grants
    • How eligibility works
    • Applying for grants
    • Wait lists
    • FundFinder
    • PAN portals
    • Using and managing grants
    • Patient reimbursements
    • Pharmacy claims
    • Provider claims
    • Partners and other support
  • Find a disease fund
  • Stories
  • Our advocacy work  

    Our policy positions, research polling and surveys, policy letters, and Medicare reform resources

    • Our work
    • Our positions
    • Our partners
    • Policy letters and testimony
    • Polling and surveys
    • The need for patient assistance programs
    • Medicare reforms
    • Become an advocate
  • Support PAN  

    How you can support the PAN Foundation

    • Ways to give
    • Give every month
    • Share your story
    • Become an advocate
    • Connect at events
  • Donate
    • Patient portal
    • Pharmacy portal
    • Provider portal
    • FundFinder
  • About us
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Sample Claim Form

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Sample Claim Form (pdf 802.13 KB)

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We help underinsured people with life-threatening, chronic, and rare diseases get the medications and treatments they need by assisting with their out-of-pocket costs and advocating for improved access and affordability.
Charity Navigator Score 100 out of 100 Guidestar Platinum Transparency 2021 2021 Top Rated Great Nonprofits America's Favorite Charities 2021

95%

OF ALL DONATIONS GO DIRECTLY TO PATIENTS.

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Charity Navigator Score 100 out of 100 Guidestar Platinum Transparency 2021 2021 Top Rated Great Nonprofits America's Favorite Charities 2021
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