Follow the steps to complete the application effectively.

1. Click ‘Get Form’ button to obtain the application and open it in an interactive format.
2. Fill in the prescriber information, including the prescriber’s name, practice details, contact information, and license number.
3. Provide the patient's personal information, including their name, address, date of birth, social security number, and primary contact details.
4. Complete the income information section by entering the current annual household income and the number of individuals residing in the household.
5. Detail the patient's insurance information, indicating whether they are uninsured or if they have insurance, and attach a copy of the insurance card if applicable.
6. Ensure that all required documentation is attached, including the most recent W2 or 1099 form for income verification, a photocopy of the insurance cards, and a denial letter for the Low-Income Subsidy if applicable.
7. Review the entire application for completeness, ensuring all fields are filled out, and that the prescriber and patient have signed where necessary.
8. Once the application is complete, fax it along with the required documentation to 1-800-910-4610 or mail it to Radius Assist Patient Assistance Program, PO Box 5536, Louisville, KY 40255.

Start filling out the PA Radius Health Assist Program Application online today to take the first step toward receiving the assistance you need.