Secure document upload form

Are you a patient?(Required)

Yes

No

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

Please fill out the following information so we can verify your identity:

You can upload documents on behalf of the patient. We’d like to gather your contact information in case we need to reach out with any questions.

First Name(Required)

Last Name(Required)

Email Address(Required)

Phone Number

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 (optional)

Patient's Phone Number(Required)

Patient's Date of Birth(Required)

Patient PAN Member ID (optional)

Does this all look correct?

Please describe the issue to the best of your ability and upload the appropriate documents.

Description(Required)

Upload files here(Required)

Drop files here or

Accepted file types: pdf, png, jpg, jpeg, doc, docx, Max. file size: 10 MB, Max. files: 33.

Does this all look correct?

Review and consent to our terms and conditions

Read carefully before you submit the 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 submitted 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.

I agree

Comments

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Secure document upload form

Secure Document Upload

Review and consent to our terms and conditions