* Required Field
Which diagnosis do you need assistance for?*
Patient Date of Birth:
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 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.
For our Premium Assistance Program, do you have health insurance coverage?*
In order to be eligible for Premium Assistance you must have or be in the process of securing health insurance coverage for the approved medication(s).
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: