Welcome to Find Prescription Relief's Drug Assistance Application Form
Complete this form to qualify for medication assistance.
What is your first name? *

As it appears on your birth certificate or medical records.
What is your last name? *

As it appears on your birth certificate or medical records.
What is your mobile phone number? *

Please include the area code.
What is another phone number you can be reached at?

Please include the area code.
What is your biological sex? *

Which year were you born in? *

On which day of {{answer_vQhvgAX5G8Rn}} {{answer_EwcFiRFFziCs}} were you born? *

Thank you for sharing your personal details.  Keep in mind, all information is protected through HIPAA privacy laws.

{{answer_zgC9zVRMuDCC}} in finishing your enrollment for medication assistance, we will be asking medical and income information required by pharmaceutical assistance programs. *This Is To Qualify For $0 Copay*

Would you prefer to complete your application online or speak with a licensed advocate who can answer questions over the phone? *

Any and all information submitted is electronically encrypted & safeguarded according to HIPAA compliance standards.*

Do you currently have Medicare A or B? *

You may be covered by just Medicare A  or both Medicare A & B

Do you currently have a group or private health insurance plan? *

You may be covered by your workplace or a family member.

What company do you currently have insurance with? *

Either on Medicare, Medicaid, Group or Private insurance coverage. Please enter the name.
Do you currently have Medicare part-D coverage? *

You may be covered by Medicare without drug coverage.

Are you currently in the doughnut hole for your Part D? *

If you are unsure, please ask your health professional about a free pregnancy test.

What month either current, past or future, do you expect to enter or have entered the doughnut hole with Part D? *

Answers don't have to be exact. If your not sure, answer according to past years or provide your best educated guess.

How much do you pay in total (or will pay) monthly for ALL brand-name medications you take or should be taking?

If you avoid filling your prescriptions due to price, include the costs if you were able to afford the medication. *

Do not include the costs insurance pays each month.  Please enter the amount of your personal expenses each month for medicine alone. Do not include drugs amounts that are covered by insurance.
Please enter the NUMBER of Brand Medications you are currently prescribed? *

This number can include generic medications you are currently prescribed.  However, due to cost, you elected the generic medication  BUT you should or prefer to take the brand name equivalent.
To determine your eligibility. Please detail prescribed medication(s).
List the Name, Type & Dosage for each below. *

*Enter one medication for each line. Remember, include the name, type and dosage. 

*Be careful to list all of them.
What is your street address?

What is your city and state?

What is your postal code or zip code?

Please confirm the following details.

Monthly Rx Costs : *{{answer_sH0Uox63Bvw3}}
# of Brand Meds    : *{{answer_67155439}}
Medication List     : *{{answer_zO46yO2mwTu2}}

Street Address      : {{answer_XwtusJeO8Mvc}}*
City & State            : {{answer_vzL0wvOkp6qM}}*
Zip Code                  : {{answer_uTohhK51Htg0}}

Immediate : 
If Additional Questions Are Needed:*

Mobile Phone      : {{answer_AgAQ7KrLcV3U}}
Other Phone        : {{answer_66336639}}
Please confirm the following details.

First name : *{{answer_zgC9zVRMuDCC}}
Last name  : {{answer_66330838}}
Email            : {{answer_Zwbn8gQhm9Ni}}*
Gender        : *{{answer_Lr4mR0z8fzeL}}
DOB              : {{answer_vQhvgAX5G8Rn}} {{answer_ewBUqScczsDm}}, {{answer_EwcFiRFFziCs}}
Insurance  : *{{answer_66332121}}
Medicare   : {{answer_66336821}}
Part D         : {{answer_66332121}}

Mobile Number : {{answer_AgAQ7KrLcV3U}}
Other Number   : {{answer_66336639}}
Thank you {{answer_zgC9zVRMuDCC}}.
Part 1 of your patient application has been received and sent to our specialists where your case will be assigned a medication advocate for review.

Based on the answers given, in order to complete Part 2 of your application you will need to speak with a prescription advocate we've personally assigned you.*
Advocate Has Been Assigned. Click For Your Reference #
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