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Sign-Up Form

Complete the following form to sign-up today.
ALL information is required to qualify you to receive your prescription drugs assistance.

CONTACT INFORMATION
Your Email
First Name
Middle Name (optional)
Last Name
Home Phone
Mobile/Cell Phone (optional)
Please Call Me At Home Mobile/Cell Work No pref.
Best Time to Call
Address
(optional 2nd address line)
City
State
Zip
PERSONAL INFORMATION
Date of Birth
Are You a U.S. Citizen Yes No
Are You a U.S. Veteran Yes No
Are You Disabled Yes No
Current Marital Status Married Legally Separated Widowed
Divorced Never Married
Number of Dependents
YOUR FINANCIAL INFORMATION:
Please enter your average MONTHLY income from the following sources.
Your spouse's income will be entered below, if applicable.
Place a "0" (zero) in un-applicable fields.
Your Current Wages
Interest
Alimony
Unemployment
Disability
Social Security
Supplemental
Pension
Other
ADDITIONAL INFORMATION:
Do You Have
Private Insurance 		Yes No
Comments or Questions
SIGNATURE RELEASE:
Your signature is required on certain forms to obtain drugs on your behalf.
For your convenience, and because contact with you as a patient may be difficult,
we are asking for your permission to sign these forms on your behalf when
seeking aid from drug manufacturers.
Signature Consent Yes No
 
I AUTHORIZE MY PATIENT ADVOCATE TO SIGN AS MY AGENT ON APPLICATIONS
AND FORMS REQUIRED FOR MEDICATION ASSISTANCE PROGRAMS
Please type ""

 
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