Enrollment Form
* Required Field
Step 1
Assessment
Step 2
Information
Step 3
Conditions
Step 4
Review
Step 5
Confirm
Which diagnosis do you need assistance for?*
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?*
No Funds Available
Funding is currently exhausted for this disease state and The Assistance Fund is not accepting applications at this time. Please check back frequently for updates.
Thank you
Thank you for your interest in The Assistance Fund. Based on the details provided, please contact a Patient Advocate to provide additional information Monday through Friday from 9:00am - 6:00pm (EST), excluding holidays.
Thank you
Thank you for your interest in The Assistance Fund. At this time you must be a US citizen or a permanent resident to receive assistance.
What program(s) are you applying for? Check all that apply.
For our Copay Assistance Program, do you have insurance coverage for the related therapy?*
In order to be eligible for copay assistance, you must have insurance coverage for the specialty medications.
In order to be eligible for copay assistance, you must have insurance coverage for the specialty medications. If you need help getting insurance please continue with the application for Premium Assistance.
For our Premium Assistance Program, do you have health insurance coverage?*
Thank you for your interest in The Assistance Fund Copay Assistance Program. In order to be eligible for our Copay Assistance Program, you must have primary insurance but need help with your copay for specialty medications.
Thank you for your interest in The Assistance Fund Premium Assistance Program. In order to be eligible for our Premium Assistance Program, you must have or be in the process of obtaining health coverage and in need of help with insurance premium costs.
Thank you for your interest in The Assistance Fund. In order to be eligible for our Copay Assistance Program, you must have primary insurance but need help with your copay for specialty medications. In order to be eligible for our Premium Assistance Program, you must have or be in the process of obtaining health coverage and in need of help with insurance premium costs.
The Assistance program can only only assist patients with insurance to help cover their co-payments.
The selected diagnosis does not offer assistance at this time. Please check back as it may be added in the future.
Thank you for your interest in The Assistance Fund.
If you need help completing the enrollment form, please contact a Patient Advocate Monday through Friday at (855) 845-3663, 9:00am - 6:00pm EST, excluding holidays.
You can also chat with a Patient Advocate by clicking below:
