Patients may enroll in any of our programs either directly through the Fund or through one of our participating pharmacies. Patients are enrolled on a first-come-first-served basis. We do, in certain circumstances, maintain a patient waiting list for assistance. Should this apply, we would contact each patient on the list in chronological order to determine if they still need assistance. Patient assistance is limited by the financial donations given to the Chronic Disease Fund.

To apply for assistance, please fill out the following form or Contact Us during normal business hours. If we are unable to answer your call due to call volume, please leave a message and your call will be returned as soon as possible.

You must print out an Application and HIPAA Authorization
and fax them to (214)570-3621
or mail them to:


If you cannot print these documents, please fill out the form and we will send them to you.

Name:
Phone Number:
Best time to Contact:
Email:
Diagnosed Disease:
Medication Required:
State of Residence:
Annual Household Income:
Number of people in Household:
Insurance Company Name:
Prescription Deductible/Copay Amount: