PAP Application

Please complete and submit the Patient Assistance Application below, or download, print, complete and fax the PDF application form to

1-888-503-6982

Download Patient Assistance Application

Patient Care America Application for Patient Assistance Program (PAP)

(Secure and HIPAA Compliant)

Patient Information:

Patient Name

First

Last

Language

Patient Phone

SSN

Date of Birth

day

month

year

Patient Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Marital Status

Number of Dependants

MONTHLY Household Information

Monthly Household Income

Number of Household Members

Gross Pay

Pension

Disability

Social Security

Other

Total Monthly Income *

Monthly Household Expenses

Mortgage / Rent

Utilities (Inc. Phone & Cable)

Transportation

Child Care

Food

Medical Expenses

Other Expenses

Total Monthly Expenses*

Upload Support Documents:

Please upload proof of Income such as a Bank Statement, SSI Letter; W2 or Check Stub.

Upload Support Documents: *

PLEASE NOTE: INCOMPLETE APPLICATIONS WILL BE RETURNED. Signatures are required by patient/legal representative.

PATIENT CERTIFICATION By signing this application, the patient certifies that the financial information provided is true and accurate for

Patient Care America to consider patient assistance. The patient agrees to notify PCA of any changes to their financial status and that the information provided on this application may be verified.

Signature*

Date*