Acknowledgments
I certify that the information provided on this application is true and accurate to the best of my knowledge. I understand that Reach Patient Assistance will act as an advocate on my behalf to obtain free or low-cost medications, but I am responsible to obtain my own medicine in the event I should run out for any reason. I agree to pay for up to 90 days if I am approved for the program and then cancel medication processing through Reach Patient Assistance, LLC.
I assume all responsibility for notifying the Reach Patient Assistance, LLC of changes made to medication regimens and/or treatment plans. I understand that if I fail to notify the company of medication changes prescribed by my physician, I may receive medications potentially hazardous to my health, constituting medication for which no current prescription exists.
In consideration for the services provided by Reach Patient Assistance, LLC, I hereby agree to pay a one-time enrollment fee of $25 for the purpose of processing initial paperwork for the pharmaceutical manufacturer(s) to determine my eligibility for PAP programs, and a quarterly paperwork processing fee of $36 per medication I receive (auto draft) or $45 per medication (mailed invoice). I understand these fees can be paid monthly at $12 per medication for auto draft or $15 per medication for monthly invoice. Paperwork processing costs for generic medications may vary from these amounts.
By selecting the Draft Payment or Credit Card billing options I authorize Reach Patient Assistance, LLC to initiate debit/credit entries to the account indicated, and the depository institution named is authorized to debit/credit the same to such account. This authority can be terminated by me or my agent at any time by written notification to Reach Patient Assistance, LLC, provided only that Reach Patient Assistance, LLC and the depository will have a reasonable opportunity to act on such notification. By my signature below I agree to the conditions of the client authorization for draft payments visa/mc/discover/debit card.
I agree to keep my account in good standing and promptly pay all applicable service fees. I agree to pay late charges and reasonable collection costs if my account should become delinquent, and I understand further services will be suspended until my account balance is brought current or payment arrangements have been made.
I understand that not all medications are available through the assistance program. In the event a medication is unavailable or becomes unavailable through the program for any reason, I will be responsible to obtain those medications through traditional methods until they are made available again on the assistance program.
I understand that the availability of medications may change at any time without notice. Reach Patient Assistance, LLC cannot guarantee the availability of any medication. I accept responsibility to obtain these medications on my own when unavailable through the program. I understand that four to six weeks may be required to complete the application process and delivery of medication.
I understand that medications may be delivered to my home, to the doctor’s office or to a local pharmacy. Each pharmaceutical company has a preferred method of delivery. I also understand that some pharmaceutical companies charge a small co-pay when a medication is picked up at a local pharmacy (usually between $5 - $15) and that I am responsible to pay this fee to receive my medication.
Reach Patient Assistance understands that your medical and health information is personal. Protecting your health information is important to us. The information you provided on this application will be used for the sole purpose of helping you obtain the medications listed and others that may be added. We do not sell any information contained herein or provide it to any third party for marketing purposes.
By submitting my application online I agree to the terms and conditions above.
I assume all responsibility for notifying the Reach Patient Assistance, LLC of changes made to medication regimens and/or treatment plans. I understand that if I fail to notify the company of medication changes prescribed by my physician, I may receive medications potentially hazardous to my health, constituting medication for which no current prescription exists.
In consideration for the services provided by Reach Patient Assistance, LLC, I hereby agree to pay a one-time enrollment fee of $25 for the purpose of processing initial paperwork for the pharmaceutical manufacturer(s) to determine my eligibility for PAP programs, and a quarterly paperwork processing fee of $36 per medication I receive (auto draft) or $45 per medication (mailed invoice). I understand these fees can be paid monthly at $12 per medication for auto draft or $15 per medication for monthly invoice. Paperwork processing costs for generic medications may vary from these amounts.
By selecting the Draft Payment or Credit Card billing options I authorize Reach Patient Assistance, LLC to initiate debit/credit entries to the account indicated, and the depository institution named is authorized to debit/credit the same to such account. This authority can be terminated by me or my agent at any time by written notification to Reach Patient Assistance, LLC, provided only that Reach Patient Assistance, LLC and the depository will have a reasonable opportunity to act on such notification. By my signature below I agree to the conditions of the client authorization for draft payments visa/mc/discover/debit card.
I agree to keep my account in good standing and promptly pay all applicable service fees. I agree to pay late charges and reasonable collection costs if my account should become delinquent, and I understand further services will be suspended until my account balance is brought current or payment arrangements have been made.
I understand that not all medications are available through the assistance program. In the event a medication is unavailable or becomes unavailable through the program for any reason, I will be responsible to obtain those medications through traditional methods until they are made available again on the assistance program.
I understand that the availability of medications may change at any time without notice. Reach Patient Assistance, LLC cannot guarantee the availability of any medication. I accept responsibility to obtain these medications on my own when unavailable through the program. I understand that four to six weeks may be required to complete the application process and delivery of medication.
I understand that medications may be delivered to my home, to the doctor’s office or to a local pharmacy. Each pharmaceutical company has a preferred method of delivery. I also understand that some pharmaceutical companies charge a small co-pay when a medication is picked up at a local pharmacy (usually between $5 - $15) and that I am responsible to pay this fee to receive my medication.
Reach Patient Assistance understands that your medical and health information is personal. Protecting your health information is important to us. The information you provided on this application will be used for the sole purpose of helping you obtain the medications listed and others that may be added. We do not sell any information contained herein or provide it to any third party for marketing purposes.
By submitting my application online I agree to the terms and conditions above.
Reach Patient Assistance, LLC
Toll-Free Phone: 1-888-727-8633
Toll-Free Fax: 1-866-727-8633
[email protected]
Toll-Free Phone: 1-888-727-8633
Toll-Free Fax: 1-866-727-8633
[email protected]