Get For Prep Medication Assistance Program

This guide provides detailed instructions for completing the for PrEP Medication Assistance Program application online. By following these steps, users will be able to navigate the form efficiently and ensure all necessary information is provided for successful enrollment.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the applicant information section. Fill in your full name, date of birth, address, city, state, zip code, and phone number.
3. Provide your social security number and indicate your gender, ensuring to check the box confirming your residency in the U.S. or U.S. territories.
4. Identify a primary contact and their relationship to you. This may be a partner, friend, or family member, and provide their contact number.
5. In the applicant financial information section, select the number of people in your household and fill in your current annual household income. Attach current documentation of income as instructed.
6. Indicate whether you are insured or uninsured. If insured, fill in all applicable insurance details and attach a copy of your insurance card.
7. Further, provide any additional insurance information if you have applied for Medicare Part D or Medicaid. Include dates of application if applicable.
8. Proceed to the prescriber information section. Enter the prescriber's name, their title, facility name, address, and contact information.
9. Fill out the statement of medical necessity, ensuring it is signed and dated by the prescriber. This section is crucial for confirming your eligibility.
10. Review all provided information for accuracy and completeness. Ensure all required fields are filled out.
11. Save your changes, download, or print the form if needed. Then, submit the completed application along with the required documents by faxing it to the specified number.

Complete your application online to access the PrEP Medication Assistance Program.