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Medication Patient Assistance Application

Breathe PA is revamping it's medication assistance program to provide medication to individuals with a respiratory diagnosis who are experiencing financial hardship, and is open to residents in the following counties:
Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland. 

This application is designed to be completed by the individual requesting assistance for themselves or their family member. If approved, Breathe PA will work with our partner pharmacy to provide two months of respiratory medication, totaling up to $300/month, to the patient. Medication is mailed directly to the patient's home. This application is a screening tool that allows Breathe PA to collect information to determine patient qualification for the program. If approved, addition information is required, which at a minimum includes:

1. Confirmation of respiratory diagnosis by your doctor's office
2. Respiratory medication prescriptions from doctor's office
3. Copy of the front and back of patient's insurance card

Our office will be in contact to let you know if you qualify to participate in the program. Please allow 5 business days for someone to contact you. Do not send any additional information until you have been approved for the program. This program is subject to change at any time. If you have any questions please call (724) 772-1750 or email info@breathepa.org. 

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* 1. Application Date

Date

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* 2. Patient's First and Last Name 

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* 3. Patient's Street Address

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* 4. Patient's City

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* 5. Patient's State (Ex: PA)

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* 6. Patient's Zip Code

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* 7. Patient's County

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* 8. Patient's Phone Number, including Area Code (if a child, please enter phone number of Parent/Guardian)

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* 9. Has the patient been diagnosed with a chronic respiratory disease? (Ex: COPD)

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* 10. How many people live in the patient's household? Include adults and children in this total (This information is required to help determine financial need).

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* 11. What is the CURRENT combined pre-tax MONTHLY income from all adults in the household? Include all sources of income (This information is required to help determine financial need).

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* 12. Who is your health insurance provider? (If approved, you will need to provide Breathe PA a copy of the front and back of your insurance card. Additional information may be required by the pharmacy).

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* 13. Enter the name AND phone number of the physician or physician practice that will be sending prescriptions.

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* 14. What medications are you requesting be refilled?

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* 15. What is YOUR relationship to the patient?

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* 16. What is YOUR First and Last Name?

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* 17. What is YOUR email address? 

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* 18. I agree that the information provided is accurate. 

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* 19. I understand that if approved, I must provide additional information to Breathe PA for them to process the request. I understand that I must provide the additional information requested by Breathe PA within 7 business days after receiving assistance approval. Failure to provide documentation within 7 days will result in the application being terminated.

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* 20. I agree that I am experiencing a financial hardship or have limited income, making it difficult to afford my respiratory medications.

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* 21. I agree that if approved for medication assistance, Breathe PA may contact the physician or physician practice to confirm the patient's chronic lung disease diagnosis.

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* 22. Enter any questions or comments below.

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