Patient Enrollment

Transportation Assistance Fund

Congratulations! You qualify for additional travel assistance.

The Transportation Assistance Program provides you with an additional grant of $ via a prepaid debit card that can be used to qualified non-emergency travel and lodging services.

Would you like to enroll in the Transportation Assistance Fund?

Yes

Available Services

Your Selection(s)

You must select a service to continue.

More information regarding the Transportation Assistance Fund will be sent to via your preferred communication method. Your debit card mailing address will be confirmed in an upcoming screening.

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Travel Assistance

Patient's Home Address:

To qualify for PAN’s travel assistance programs, the patient must be required to travel more than 20 miles (one way) to receive his or her prescribed treatment. Exceptions to distance requirements are made for patients living in large metropolitan cities. See PAN’s Travel FAQs for details.

Please find additional details on PAN's Travel FAQ .

Search for your Treatment Facility

Treatment Facility	Address	City	State	ZIP

Can't find your treatment facility?

Add your Treatment Facility

*Treatment Facility:

* Street Address:

Suite / Bldg #:

* City:

* State:

* ZIP:

Phone Number:

Phone Ext:

Fax Number:

Your treatment facilities

Treatment Facility	Address	City	State	ZIP	Distance from home	Action

Please attach copy(ies) of your appointment schedule.

Upload File

Document Name	Size	Date

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Treating Provider

You may search for your provider by entering the below search fields. You must enter either an NPI, or a Last Name and State to search for a provider. If you cannot find your provider, please reach out to the PAN call center at 1-866-316-7263.

NPI number is missing for the physician record associated with the patient's application. Please use the search feature above to locate and select a valid physician.

Physician details

Provider Name:

NPI:

Practice:

,

Phone:

Email address:

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Education and Support Services

The PAN Foundation partners with the following organization(s) to provide education and support services to patients. If you would like to be contacted by an organization(s) below, please check that box and enter the requested information.

Patient First Name

Patient Middle Name

Patient Last Name

Patient DOB

How would you like to be contacted? Please enter the requested information below and select your preferred method of contact.

Please select and enter your preferred contact method below.

*Email

Preferred contact method

*Phone

Preferred contact method

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Copay Assistance Programs

Assistance Program Name	Drug/Medication Name	Phone Number	Address

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Review

Pre-screen questionnaire Edit

Please review your enrollment application for the Fund below

Selected medication(s)

Transportation Service(s)

The medication(s)

is no longer covered. Please select another medication from the formulary.

The medication(s)

is no longer covered, but the grant can still be used for your other medications.

Is the patient living and receiving treatment in the U.S. or U.S. territories?

Does the patient have insurance coverage?

What type(s) of Insurance does the patient have?

How many people live in the patient's home?

What is the patient's Adjusted Gross Income (See IRS form 1040 Line 37, or Form 1040A Line 21 or Form 1040EZ Line 4)?

23,000

Transportation Assistance Fund

Enroll

Patient information Edit

F. Name

M. Name

L. Name

SSN

DOB

Gender

Address

Apt/Ste

City

State

ZIP

Phone

Race or Origin

Preferred Method of Communication

PAN debit card shipping address is different from address above

Authorized Contact

F. Name

L. Name

Relation

Phone

Patient insurance Edit

Primary Insurance

Insurance Name

Cardholder ID

Payer Type

Group Number

Phone

Treating Provider Edit

F. Name

L. Name

NPI

Phone

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Attestation

Application Submission

I attest and certify under penalty of law that the information provided in this application for financial assistance is accurate and complete.

Authorization to Release Medical Information

I authorize my healthcare provider(s) and my insurance company(ies) to disclose to the Patient Access Network Foundation, its third party administrators, and other representatives information about me, my current medical condition and my health insurance coverage. I understand that while the Foundation will make every effort to keep my information private, there are circumstances under which the Foundation may be required to disclose my information to others.

I understand and agree that the Foundation may: i. seek additional information about me from others; ii. modify its eligibility criteria at any time; or iii. modify or terminate assistance at any time.

Applicant Declaration

I agree with all attestations presented above.

I am authorized to complete this application on behalf of the patient.

Person Assisting the Patient

I am attesting that I have informed the patient of the above information and that the patient agrees with it or that I have the authority to make decisions on behalf of the patient and that I agree to the above attestations on behalf of the patient.

*First Name

*Last Name

*Email Address

*Phone Number

Signed Certification Date

3/28/2023 1:41 AM

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Eligibility Pre-screen

Eligibility Pre-screen: Select a Different Disease Fund

Select medication(s)

Selected medication(s)

Eligibility Pre-screen: Select a Different Disease Fund

Selected medication(s) Edit

You are eligible to continue.

Transportation Assistance Fund

Available Services

Your Selection(s)

Patient Information

How do you identify your race or origin? Select all that apply.

Patient Insurance

Insurance

Travel Assistance

Treating Provider

Physician details

Education and Support Services

Review

Pre-screen questionnaire Edit

Selected medication(s)

Transportation Service(s)

Patient information Edit

Patient insurance Edit

Primary Insurance

Treating Provider Edit

Attestation

An existing patient with the same information was found in our records. Fields will be prepopulated with that data. Please review and edit as needed.

The patient is already enrolled in the selected disease fund.

Please contact the PAN call center at 1-866-316-7263 to complete the enrollment.

Pre-Screen Eligibility: Wait List ID