Patient
Medication
Assistance
Helping you receive the medication you need without the hassle or expense

Paying for prescription drugs can be very costly, especially if you have no insurance or make little money to pay for expensive medication.

Patient Medication Assistance will locate free medication for you. Hundreds of Pharmaceutical companies give out free medications under patient assistance programs. Most pharmaceutical companies do not advertise or widely promote these programs. Patient Medication Assistance will help determine your eligibility for the patient assistance programs and assist you with completing the proper paperwork required by each pharmaceutical company.

Each pharmaceutical company has its own requirements. In most cases to be eligible for free medication applicants must show that:

* You do not have prescription drug coverage.

* Your income is low enough that paying for prescription drugs is very difficult.

* Approximate income for individuals $24,000 or less; 2 people in household $40,000 or less.

* You do not qualify for Medicaid or other government assistance programs.

Program Features:

* Mail you completed pharmaceutical applications that only require signatures.

* Check your forms for completeness and eliminate any unnecessary paper work.

* Keep track of any changing eligibility requirements.

* Keep a current data base of almost 200 pharmaceutical companies.

* Personal service M-F 9:00 a.m. to 5:00 p.m.

How it works

1) Please complete your Patient Information and Medication forms and return with payment in provided envelope. Also choose delivery option.

2) Once we receive your information, we will mail you completed pharmaceutical applications for your signature and review.

3) Sign all applications and return in postage provide envelope.

4) We will work closely with your doctor’s office to have their portion completed.

5) Patient Medication Assistance will review your pharmaceutical application for accuracy, and then forward all applications to the appropriate pharmaceutical company.

6) After the pharmaceutical companies approve and process your application, you should expect to start receiving your medications in 2 to 4 weeks.

7) Patient Medication Assistance will track your medications for renewal and complete all applications needed to reapply for your medications.

Customer Service M-F 9:00 a.m. to 5:00 p.m. 1-866-353-9377 or 317-838-0671

For more information please visit our website

Patient
Medication
Assistance
Helping you receive the medication you need without the hassle or expense

Patient Medication Assistance charges for the administrative service of managing and tracking prescription medications received with our assistance. The medications themselves are free from the pharmaceutical companies. We keep a data base with more than 200 pharmaceutical companies that offer free medications, however Xubex and RX Outreach charge a small co-pay or delivery charge.

Monthly Service Fee

We charge a $32.00 monthly service fee to manage your patient assistance programs. We will also work with your doctor’s office and pharmaceutical companies to help ensure fast and accurate refills of your medications.

We bill our clients $32.00 monthly regardless of the number of medications. Your service is pre-paid each month and you may cancel at any time with a 30 day written notice.

Example:

In January you begin receiving 5 medications (you pay $32.00 per month)

In February you add additional medication (you still pay only $32.00 per month)

You should receive your first statement in 30 to 45 days.

Money Back Guarantee

We do not accept all applications. If we feel based on the information you provide, that you will not qualify for assistance, you will receive a full refund within 10 business days.

Over 98% of the applications we send to the pharmaceutical companies are approved. If for any reason you are denied assistance for all of your medications, we will refund all service fees paid within 10 business days of notification.

Customer Service

Once we receive your completed application, you will be assigned a customer care representative. Your representative will complete all necessary applications and work closely with your doctor’s office. Your representative is available to assist you Monday –Friday 9:00 a.m. to 5:00 p.m. (Eastern Standard Time)

Customer Service 1-866-353-9377

PATIENT INFORMATION FORM
Patient First Name / M.I. / Patient Last Name
Full Mailing Address (Include street name, apartment number, P.O. Box number)
City / State / Zip Code
- / - / - / -
Area Code / Telephone Number / Date of Birth (MM-DD-YYYY)
- / -
Social Security Number / Female / Male / Medicare / Medicaid
Are you Disabled? / YES / NO
Married / Single / Divorced / Widow
Do you currently have prescription drug coverage? / YES / NO
Total number of dependents, including yourself, in the household
Did you file taxes in 2008? / YES / NO
Your gross monthly household income / $______
( If you are married, you must include both incomes.)
Please list all sources of income:______
I understand that:
1. Each pharmaceutical company must approve my application, and that some medications
may not qualify.
2. I am paying Patient Medication Assistance a $28.00 monthly service fee.
3. I will receive a full refund if it is determined that I am ineligible for medication assistance.
4. For my convience most medications are shipped directly to my home or doctor's office in a 3 month
supply.
5. It normally takes 2-8 weeks for most pharmaceutical companies to ship your medication.
6. Patient Medication Assistance does not handle or ship any medications. Your medication
comes directly from the drug manufacturer.
Signature of Applicant:______Date:______
(Example S.S, Disability, Wages, etc.)
Please enclose a check for $28.00 with this completed package to:
Patient Medication Assisatnce
8103 East U S Highway 36 #245
Avon, Indiana 46123
Please enclose proof of income for all living in household.
Example: Social security statement, pay stub, most recent taxes etc.
All information provided is confidential and only used
for the purpose of obtaining medications through Drug Assistance programs.
PATIENT MEDICATION FORM
123A / Name of Medication / Strength / Quantity Per Day / Doctor's Name / Doctor's Phone Number
EXAMPLE / Synthroid / 40 mg / 2 / Joe Jones / (317) 123-4567
1
2
3
4
5
6
7
8
9
10
Please print correct spelling of medication and do not send prescriptions with application.
Please enclose a check with completed application to: Patient Medication Assistance 8103 East US Highway 36 # 245 Avon, Indiana 46123
Patient
Medication
Assistance
Helping you receive the medication you need without the hassle or expense

Please note, we do not handle or ship medications and are not affiliated with any pharmaceutical company or drug manufacturer. We are a fee-based service that will assist you in obtaining medications through patient assistance programs. For your monthly service fee we provide the following:

  • Locate and complete pharmaceutical applications to apply for drug assistance.
  • Full customer support – Available 9:00 a.m. to 5:00 p.m. Monday to Friday.
  • Complete management of multiple Drug Assistance Programs.
  • Provide postage cost related to your pharmaceutical applications.
  • Mail all applications to your doctor for approval and attach any necessary documents.
  • Review all applications for accuracy before forwarding to the pharmaceutical company.
  • Track your medications for renewal and complete appropriate applications (usually every 90 days).
  • You may add new medications at any time with no increase in your monthly service fee.

Our goal is to help you receive your medications through Drug Assistance Programs with little hassle or expense.

By signing below I understand that: 1) Each pharmaceutical company must approve my application, and some medications my not qualify. 2) I will receive a full refund if it is determined that I am ineligible for Drug Assistance Programs. 3) I am paying Patient Medication Assistance $32.00 per month for locating, completing pharmaceutical applications, and tracking medications received with their assistance. 4) I am not paying for pharmaceutical applications and most can be obtained for free. 5) I will be assigned a customer service representative that will manage my drug assistance applications and perform administrative work to receive drug assistance. 6) Patient Medication Assistance will be in contact with my doctor’s office to have their portions of pharmaceutical applications completed. 7) Any delays at my doctor’s office may result in a delay in receiving medications. 8) Each pharmaceutical company determines where my medications are shipped; in most cases my medications will be shipped to my doctor’s office in a 90-day supply. 9) Once the pharmaceutical companies approve my applications, it normally takes 2 to 4 weeks to receive my medications. 10) Patient Medication Assistance will automatically send me applications to re apply for drug assistance approximately 45 days before I am out of medicine. 11) Patient Medication Assistance is not liable for wrong medications shipped by drug manufacturers or any time I run out of medication received through drug assistance programs. 12) If I run out of medications I should purchase my medication while waiting for drug assistance. 13) I may cancel at any time with a 30 day written notice.

______

Patient signaturePrinted nameDate

Patient
Medication
Assistance
Helping you receive the medication you need without the hassle or expense

Delivery Options

Standard delivery- Patient Medication Assistance will process your application within 72 hours and forward all applications standard mail to address provide. You should receive your completed applications in 6 to 10 days.

Priority delivery- Patient Medication Assistance will process your application the same day and Priority mail the completed applications to the address provided. You should receive your applications in 2 to 3 days.

Overnight delivery- Patient Medication Assistance will process your application the same day and overnight the completed pharmaceutical applications to the address provided for signatures. We will provide a pre-paid return overnight envelope and process your applications the same day with priority delivery to each pharmaceutical company. You could receive your medications in as little as 10 days.

Other Services

Premium Membership- Our premium service will help eliminate the need for you to sign refill applications. Patient Medication Assistance will print approximately one full year of applications that require your signature. You will need to review the applications and sign in the yellow highlighted areas. After we receive the applications from you, we will hold them in your file and use as needed throughout the year. By signing refill applications now, you can help ensure faster refills on your medications.

My Medical Journal- My medical Journal is an easy to use health record. My Medical Journal allows you to keep track of your medications, hospital visits, and medical history. Your doctor also documents each visit directly in the journal, such as: blood pressure, weight, pulse, Office test, and doctor’s advice or actions required. My Medical Journal allows you to have quick and convenient access to your medical records to share with doctors or family members.

Delivery Options

Standard delivery- Please enclose a check for $32.00 plus $17.00 account set up fee. $49.00 total

 Priority delivery- Please enclose a check for $89.00 (Includes first months payment and set up fee.)

 Overnight delivery- Please enclose a check for$149.00 (Includes first months payment and set up.)

Add on services

 Premium Membership- Please enclose a check for $69.00 plus Delivery Option

 My Medical Journal- Please enclose a check for $25.00 (Journal Only)

Delivery Option ______plus Add on Service ______Total enclosed ______

(Please write $49.00, $89.00, or $149.00) (Please write $0 no add on, $69.00, or $25.00) (Add both numbers together)

Patient
Medication
Assistance
Helping you receive the medication you need without the hassle or expense

We recommend automatic monthly bank draft. By signing up for automatic bank draft, you will not have to mail a check for you monthly service fee or worry about late fees. On your due date, we will automatically deduct your $32.00 monthly service fee from your bank account. It’s easy to get started and saves you time and money over writing a check each month. Please sign up for automatic bank draft now by completing the bottom portion of this page.

As a convenience to me, I______, request and authorize Patient Medication Assistance Inc. of Avon, Indiana to withdrawal my monthly service fee, in the amount of $32.00. I agree that my rights in respect to each payment shall be the same as if drawn by me and signed by me. This authority is to remain in effect until revoked by me in writing 20 days before next draft. I agree that you shall be protected in honoring any such check or electronic debit. Patient Medication Assistance will only charge my account $32.00 each month on my normal due date.

Please include a voided check

Signature ______Date______

Requested Draft Date (please circle) 10th 20th 30th of each month

Patient Medication Assistance Inc. 8103 E. US Hwy. 36 #245, Avon, Indiana 46123 Phone 1-866-353-9377