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Know
What is Parkinson’s?
Stages of Parkinson’s Disease
Diagnosis
Managing PD
Why Exercise?
Medication
Financial Assistance for Parkinson’s Medication
Respite Care Financial Assistance
Insurance & Legal
Know
What is Parkinson’s?
Stages of Parkinson’s Disease
Diagnosis
Managing PD
Why Exercise?
Medication
Financial Assistance for Parkinson’s Medication
Respite Care Financial Assistance
Insurance & Legal
Understanding
& Living With PD
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Exercise Benefits
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Grow
Exercise Benefits
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Tips For Getting Started
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Medication Assistance Application
Patient Information
Date
Patient Name
Contact/Caregiver Name (if applicable)
Address
City
State
Zip
Phone
Patient's Date of Birth
Financial Information
Monthly income
Relationship Status
Single
Married
Number of dependent children
Verified
Monthly cost of PD meds
Cost of other meds
Monthly/annual cost for health care
Monthly cost for health care for other immediate family members
Do you have health insurance
Yes
No
Name of insurance company
Do you have prescription coverage
Yes
No
Family member health insurance coverage?
Yes
No
Rx
Yes
No
Special Financial Concerns
Pharmacy Name
Phone
Physician Name
Phone
Name and Dose of Medication
Refills/prescription # of bottle
Allergies
Ever order through Advanced Care Pharmacy Services?
Yes
No
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