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Donnatal PAP Enrollment Form APPLICANT INFORMATION Name Date of Birth Phone Current address City S State Z ZIP Code Where did you hear about the program INCOME INFORMATION IF YOU ARE APPLYING AND ARE ON MEDICARE/MEDICADE YOU DO NOT NEED TO FILL OUT THE INCOME SECTION. List current annual household income below. Indicate the source of your income by checking all boxes that apply. Total annual income Social Security Bene ts Wages Interest/dividends Pension Unemployment Any other sources INSURANCE / COVERAGE INFORMATION Do you have prescription coverage Yes No If yes please check all that apply. Medicare Medicaid State Pharmacy Employer Other if other please list PHYSICIAN / HEALTHCARE PROVIDER INFORMATION Fax Product circle one Elixir Tablets Address DISCLAIMER I UNDERSTAND THAT THE PATIENT ASSISTANCE PROGRAM IS RESERVED FOR INDIVIDUALS THAT REQUIRE FINANCIAL ASSISTANCE TO PURCHASE THEIR MEDICATIONS AND THAT THE SUBMITTAL OF THE INFORMATION REQUESTED ON THIS FORM IS AN APPLICATION FOR CO....

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Formerly offered at 400 percent of the FPL, this expansion will mean an individual with an income at or below $60,700, or a family of four with a household income of about $125,500 may qualify for its free prescription drug program. For information please visit .TakedaHelpAtHand.com.

The MY Roche Patient Assistance Programme is for patients whose medical expenses are not fully covered by insurance, corporate benefit or any other funding from third parties as advised and justified by physicians. Since 2007 to- date, more than 8,000 patients have benefited from this on-going initiative.

PAPs offer trained staff members who help patients investigate their available coverage options. With access to a private infusion clinic, private drug plans may cover the drug but may require the patient to pay co-insurance.

The average cost of Donnatal is $423.34 for 30, 16.2MG Tablet. You may be able to pay as low as $40.10 for 30, 16.2mg Tablet of generic Donnatal with a coupon from SingleCare at participating pharmacies nationwide.

Eligibility. Roche Oncoline Patient Assistance Program, a patient assistance program provided by Roche Pharmaceuticals, offers the medications listed to the right at no cost for up to 90 days to those who are eligible for the program.

Florida Rx Card is the free statewide prescription assistance program available to all Florida residents. The program was launched in August 2007 to help uninsured and underinsured Florida residents with their prescription medication costs.

The Emergency Prescription Assistance Program, or EPAP, helps people in a federally-identified disaster area who do not have health insurance get the prescription drugs, vaccinations, medical supplies, and equipment that they need.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232