Best Time to Call
Gender MaleFemale
Marital Status SingleMarriedDivorcedWidowed
Do you have prescription drug coverage? (This does not include discount cards/programs) YesNo
Do you have a Medicare Part D Plan? YesNo
If yes, Company Name is
Did you file a Tax Return last year? YesNo
If yes, the TOTAL income on last return $
Wages YesNo Monthly Total
Patient
Spouse
Social Security YesNo Monthly Total
Disability YesNo Monthly Total
Pension YesNo Monthly Total
Unemployment YesNo Monthly Total
Other YesNo Monthly Total
Total Amount
*Total Number of People in Household
*Total Household Income
If you have no income, please explain
If your income is lower than last year’s Tax Return, please explain
Applicant
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
I agree to have Patient Help Programs and its affiliates provide the services for the sole purpose in obtaining assistance for my prescription medication(s). I also confirm that the information provided in this application is true and correct to the best of my knowledge.
I agree that this release of information will remain in effect until termination of my assistance with 'Patient Help Programs'. I understand that I have a right to revoke this authorization by providing written notice to 'Patient Help Programs'. However, this authorization may not be revoked if 'Patient Help Programs', its employees or advocates have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.
I authorize the release of information including the diagnosis, records, examination rendered to me and prescription assistance information. This information may also be released to:
Child(ren)
Other
Information is not to be released to anyone.
Message Please Call
Home
Work
Cell Number
If unable to reach me
You may leave a detailed message
Please leave a message asking me to return your call
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Name of Applicant:
Date:
Were you referred to our program by someone you know?
We hold various promotions throughout the year for referrals brought to us by our current patients, doctors' offices, insurance broker's, advocacy groups, etc. If you were referred to our program by someone who has already afforded the benefits of our service please enter their Rx Helper Patient ID Number and /or name below.
Referrals Patient ID Number and/or Referral's Name:
Yes, I agree to the terms and conditions.
By providing your phone number on this site, you consent to receive text messages from Advocate My Meds.
Text messages may include important updates on prescription assistance programs, medication reminders, and other information related to healthcare services.
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Advocate My Meds will not share your phone number with third parties without your consent.
Review our privacy policy to learn how we collect, use, and protect your information.
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We reserve the right to modify these terms and conditions at any time. Please check back periodically for updates.
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