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

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

Name of insurance company

Do you have prescription coverage

Family member health insurance coverage?

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?

If you have any questions or concerns, please contact or respite@parkinsonsmi.org.