Online Application

Step 1: Eligibility1

Step 2: Information2

Step 3: Conditions3

Step 4: Review4

Step 5: Confirm5

The program you have selected is:

Household Information

What is the patient's household size? (Household size is defined as the number of people who contribute to or are dependent on the applicant's current annual household income including the applicant.)*

What is the patient's annual household income? (Household income is based on above household size.)*


Is the patient a U.S. citizen or permanent resident?*

Does patient have insurance coverage for the related therapy?*

Does patient have health insurance coverage?*

Is the patient in the process of securing health insurance?*

Please select the type of insurance the patient has or is in the process of securing.*

Important Message:

Please review the entered data as you will not be able to change any entries after you click “Continue to Step 2".

How do you describe yourself?*

By selecting ‘I am the patient’ you are verifying that you are in fact the patient and not another entity, such as a pharmacy. In the event you are not the patient and select this option, the patient’s application may be delayed.

The assistance fund offers assistance for approved medications.

Please select the therapy the patient is currently prescribed. The therapies currently supported for the diagnosis selected are: (If this application is for a financial program and you are not seeking assistance for drug copay, please select "No current therapy")*

Preparer Information

Patient Information

Thank you for your interest in The Assistance Fund. To be eligible, a Patient must be 17 years of age or younger to receive assistance under the Juvenile Rheumatoid Arthritis Copay Assistance Program. Please review our Rheumatoid Arthritis Copay Assistance Program for availability.

Physician Specialist Information

Physician Specialist is the doctor or physician that has prescribed the patient's approved medication. Providing the following information is optional.

Additional Notes

Please include any further notes that pertain to your current financial situation or insurance coverage. Any details are encouraged to help us process your application.

Program Enrollment Agreements

Patient Authorization for the Release of Protected Health Information

Please review your information before submitting it for enrollment.

Diagnosis Information

Patient Information

Additional Notes

Physician Specialist Information