Patient Assistance Forms

Patient-assistance programs (also called PAPs) are sponsored by companies that make prescription medicines. Each company has its own rules about who qualifies for its patient-assistance program. In some cases, you will need to show that you either don’t qualify for private or public health insurance (such as Medicare or Medicaid) or you may need to prove that your income is below a certain level.

Each patient-assistance program has its own application process. For some programs you can submit an application over the phone or online. For others, the application must be mailed or faxed in. It’s important to keep in mind that applying doesn’t guarantee that you will get you medications for a free or reduced price.

Please review the application carefully for eligibility standards. Please complete each section as directed. We have completed the prescriber portion and this will need to be provided with your completed application. On each application there is an 800 number that you can contact and they will assist you with your application.

Another good idea is to check local pharmacy prices for specific medication. The cost of a prescription may differ significantly between pharmacies. GoodRx gathers current prices and discounts to help you find the lowest cost pharmacy for your prescriptions. Visit


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