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 your household size? (Household size is defined as the number of people who contribute to or are dependent on your current annual household income including yourself.)*

What is your annual household income? (Household income is based on above household size.)*

$

Are you a U.S. citizen or permanent resident?*

What program(s) are you applying for?

Do you have insurance coverage for the related therapy?*

Are you in the process of securing health insurance?*

Please select the type of insurance you have or are in the process of securing.*

How do you describe yourself?*

The assistance fund offers assistance for approved medications.

Please select the therapy you are currently prescribed. The therapies currently supported for the diagnosis selected are:*

Preparer Information

Patient Information

Thank you for your interest in The Assistance Fund. To be eligible, you 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 your 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.

2017 Program Enrollment Agreements

Patient Authorization for the Release of Protected Health

Please review your information before submitting it for enrollment.

Diagnosis Information

Patient Information

Additional Notes

Physician Specialist Information