Transcription of PATIENT ASSISTANCE PROGRAM - RxHope
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PATIENT ASSISTANCE PROGRAM - RxHope
PATIENT ASSISTANCE PROGRAM . PO BOX 42847 CINCINNATI, OH 45242. PHONE: 844-4 AGN-PAP | PHONE: 844-424-6727 | FAX: 513-618-0054. FAX TRANSMITTAL SHEET. Attn: From: Fax: Date: Phone: Number of pages including cover: Re: Re PATIENT : PATIENT ASSISTANCE PROGRAM INSTRUCTIONS. Application MUST be filled out in its entirety. FAX or MAIL completed application with income documentation to the address above. Healthcare Provider and PATIENT MUST sign the application. Patients at or below 400% of the current Federal Poverty Level are eligible for ASSISTANCE . A 90-day supply of the medication(s) requested will ship to the Healthcare Provider's office. A copy of the original application can be faxed or mailed to the address above. REORDER INSTRUCTIONS. The application is valid for one year. A copy of the application signed by the Healthcare Provider can be mailed or faxed to reorder. PATIENT may reapply as early as one month in advance.
Attn: Fax: Phone: Re: From: Date: Number of pages including cover: Re Patient: The application is valid for one year. A copy of the application …
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