Benefits Checkup

A Service of the National Council on Aging

Application Forms Center

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Program Name Sort Application Name Sort Revision Date Sort
AATmosphere Alpha-1 Security Program
Application Form in English
Abbott Laboratories Patient Assistance Program
Fillable! Application Form in English
03/01/09
Abbott Patient Assistance Foundation for Zemplar
Application Form in English
08/01/09
Abbott Patient Assistance Foundation for Zemplar
Instructions in English
08/01/07
Abbott Virology Patient Assistance Program
Application Form in English
05/01/06
Abilify Patient Assistance Program
Application Form in English
01/01/10
Abraxis Patient Access Program (APAP)
Fillable! Application Form in English
11/01/08
Aciphex Patient Assistance Program
Application Form in English
11/01/09
ACT Program for EMEND and ZOLINZA
Fillable! Application Form in English - EMEND
07/01/09
ACT Program for EMEND and ZOLINZA
Application Form in Spanish - EMEND
06/01/05
ACT Program for EMEND and ZOLINZA
Program Brochure in English - EMEND
02/01/08
ACT Program for EMEND and ZOLINZA
Application form in English - ZOLINZA
10/01/06
ACT Program for EMEND and ZOLINZA
Program Brochure in English - ZOLINZA
10/01/06
Actavis Patient Assistance Program (formerly Alpharma PAP)
Fillable! Application Form in English
03/01/05
Acthar Gel Patient Assistance Program
Referral Form in English
09/01/09
Alaven Patient Assistance Program
Fillable! Application Form in English
09/01/09
Alcon Cares, Inc. U.S. Patient Assistance Program
Application Form in English
10/01/06
Allergan Patient Assistance Program
Fillable! Application Form in English
04/01/09
Amgen SAFETY NET® Foundation Program
Application Form in English
02/01/10
Amgen SAFETY NET® Foundation Program
Patient Authorization Form in English
08/01/04
Amylin Patient Assistance Program
Application Form in English
Apligraf Patient Assistance Program
Application Form in English
Aricept® (donepezil HCl) Patient Assistance Program
Fillable! Application Form in English
10/01/07
Ascend Therapeutics Patient Assistance Program
Fillable! Application Form in English
Astellas Access Program (AAP) (formerly Amevive Patient Assistance Program)
Application Form in English
06/01/08
Atripla Patient Assistance Program
Fillable! Application Form in English
12/01/07
Auxilium Patient Assistance Program
Instructions and Application Form in English
03/01/10
Avonex Access Program
Application Form in English
05/01/06
AZ&Me for People in Medicare Part D
Online Application in English
AZ&Me for People in Medicare Part D
Application Form in English
01/01/10
AZ&Me for People in Medicare Part D
Application Form in Spanish
01/01/10
AZ&Me Prescription Savings Program (formerly AstraZeneca Patient Assistance Program)
Online Application in English
AZ&Me Prescription Savings Program (formerly AstraZeneca Patient Assistance Program)
Application Form in English
01/01/10
AZ&Me Prescription Savings Program (formerly AstraZeneca Patient Assistance Program)
Application Form in Spanish
01/01/10
Azilect Patient Assistance Program
Fillable! Application Form in English
03/01/09
Azilect Patient Assistance Program
Instructions in English
03/01/09
Bayer Patient Assistance Program
Fillable! Application Form for Angeliq in English
08/01/08
Bayer Patient Assistance Program
Fillable! Application Form for Betapace in English
08/01/08
Bayer Patient Assistance Program
Fillable! Application Form for Climara in English
08/01/08
Bayer Patient Assistance Program
Fillable! Application Form for Climara Pro in English
08/01/08
Bayer Patient Assistance Program
Application Form for Menostar in English
10/01/09
Bayer Patient Assistance Program
Fillable! Application Form for Precose in English
06/01/08
Betaseron Patient Assistance Program
Application Form in English
04/01/07
Boehringer Ingelheim Cares Foundation Patient Assistance Program
Application Form for All Drugs in English
01/01/06
Boehringer Ingelheim Cares Foundation Patient Assistance Program
Application Form for Aptivus and Viramune in English
Boehringer Ingelheim Cares Foundation Patient Assistance Program
Application Form for All Drugs in Spanish
01/01/06
Botox® Patient Assistance Program
Instructions and Application Form in English
04/01/08
Bridges to Access
Fillable! Application Form in English
04/01/10
Bristol-Myers Squibb Access Virology Patient Assistance Program
Application Form in English
05/01/10
Bristol-Myers Squibb Access Virology Patient Assistance Program
Instructions in English
01/01/09
Bristol-Myers Squibb Oncology Patient Assistance Program
Application Form in English
01/01/10
Bristol-Myers Squibb Patient Assistance Foundation, Inc.
Application Form in English
01/01/10
BTA Patient Assistance Program (formerly Biovail Pharmaceuticals, Inc. PAP)
Fillable! Application Form in English
06/01/09
BTA Patient Assistance Program (formerly Biovail Pharmaceuticals, Inc. PAP)
Instructions in English
Celgene Patient Support Program
Fillable! Application Form in English
04/01/08
Celgene Patient Support Program
Instructions in English
09/01/07
Cenestin Patient Assistance Program
Fillable! Application Form in English
10/01/08
Cephalon Oncology Reimbursement Expertise (CORE) Program
Fillable! Application Form in English
02/01/09
CephalonCares Foundation Patient Assistance Program
Application Form in English
08/01/09
Clozapine Patient Assistance Program
Fillable! Application Form in English
COMMITMENT to ACCESS
Fillable! Application Form in English
04/01/10
Commitment to Care
Application Form in English
12/01/08
Daiichi Sankyo Open Care Program
Fillable! Application Form in English
Destination Access Erbitux/Ixempra Patient Assistance Program
Fillable! Application Form in English
09/01/08
Destination Access Sprycel Patient Assistance Program
Fillable! Application Form in English
09/01/08
Doxil Patient Assistance Program
Application Form in English
11/01/09
Eisai Neurology Patient Assistance Program
Application Form in English
01/01/09
Eisai Oncology Reimbursement and Patient Assistance Program
Application Form for All Drugs in English
Eligard Reimbursement and Patient Assistance Program
Fillable! Application Form in English
11/01/08
Eligard Reimbursement and Patient Assistance Program
Instructions in English
Endo Patient Assistance Program
Application Form in English
03/01/06
Enjuvia Patient Assistance Program
Fillable! Application Form in English
10/01/08
Equetro Patient Assistance Program
Instructions and Application Form in English
03/01/09
Ferndale Laboratories, Inc. Patient Assistance Program
Application Form in English
FirstRESOURCE Patient Assistance Program
Fillable! Application Form for All Drugs in English
12/01/08
FirstRESOURCE Patient Assistance Program
Application Form for All Drugs in Spanish
12/01/08
FirstRESOURCE Patient Assistance Program
Fillable! Application Form for Sutent in English
04/01/09
FirstRESOURCE Patient Assistance Program
Application Form for Sutent in Spanish
01/01/09
Forest Pharmaceuticals, Inc. Patient Assistance Program
Fillable! Application Form in English
06/01/08
Fragmin® Reimbursement Assistance Program
Fillable! Application Form in English
Galderma Laboratories Patient Assistance Program
Fillable! Application Form in English
Genentech Access to Care
Fillable! Application Form for Herceptin in English
07/01/03
Genentech Access to Care
Fillable! Application Form for Rituxan in English
07/01/03
Genentech Access to Care
Fillable! Application Form for Xoliar in English
Genentech Access to Care
Application Form for Avastin in English
02/01/04
Gilead Advancing Access Program
Fillable! Application Form in English
Graceway Pharmaceuticals Patient Assistance Program (formerly 3M)
Fillable! Application Form in English
Grifols Patient Assistance Program
Fillable! Application Form in English
GSK Access
Fillable! Application Form in English
GTx Patient Assistance Program
Fillable! Application Form in English
01/01/08
GTx Patient Assistance Program
Instructions in English
01/01/08
HUMIRA (adalimumab) Patient Assistance Program
Fillable! Application Form in English
03/01/09
Hyalgan Reimbursement Hotline and Patient Assistance Program
Application Form in English
01/01/08
Janssen Ortho Patient Assistance Foundation Program (formerly Ortho-McNeil PAP)
Application Form in English
11/01/09
KingKare Patient Assistance Program
Fillable! Application Form in English
KingKare Patient Assistance Program
Instructions in English
Kogenate Factor Solutions Patient Assistance Program
Application Form in English
Letairis Education and Access Program (LEAP)
Fillable! Instructions and Application Form in English
02/01/09
Letairis Education and Access Program (LEAP)
Fillable! Instructions and Application Form in Spanish
02/01/09
Lilly Cares
Application Form in English
04/01/09
Lilly Oncology Patient Assistance Program
Application Form in English
01/01/08
LillyMedicareAnswers
Application Form in English
06/01/08
Lovenox Reimbursement Services and Patient Assistance Program
Fillable! Application Form in English
11/01/08
Lupron Patient Assistance Program
Application Form in English
04/01/10
Macugen Access Program
Fillable! Application Form in English
08/01/08
Macugen Access Program
Instructions in English
Meda Pharmaceuticals Patient Assistance Program (formerly Wallace Laboratories PAP)
Fillable! Application Form in English
Megace ES Patient Assistance Program
Fillable! Application Form in English
Merck Patient Assistance Program
Fillable! Application Form in English
04/01/06
Merck Patient Assistance Program
Application Form in Spanish
02/01/07
Merck SUPPORTTM Program for Reimbursement and Patient Assistance Services
Program Brochure in English
09/01/07
Merck SUPPORTTM Program for Reimbursement and Patient Assistance Services
Fillable! Application Form in English
09/01/07
Merck SUPPORTTM Program for Reimbursement and Patient Assistance Services
Application Form in Spanish
12/01/07
Merck Vaccine Patient Assistance Program
Fillable! Application Form in English
05/01/08
Merck Vaccine Patient Assistance Program
Fillable! Application Form in Spanish
10/01/07
MGI Pharma Access Program (MAP)
Fillable! Application Form for Hexalen in English
11/01/06
MGI Pharma Access Program (MAP)
Fillable! Application Form for Aloxi in English
11/01/06
MGI Pharma Access Program (MAP)
Fillable! Application Form for Dacogen in English
11/01/06
Multaq Patient Assistance and Coverage Support Hotline
Fillable! Application Form in English
Multaq Patient Assistance and Coverage Support Hotline
Instructions in English
Nexavar REACH Program
Application Form in English
05/01/07
Niche Pharmaceuticals Patient Assistance Program
Fillable! Application Form in English
01/01/09
NitroMed Cares Uninsured Patient Program
Fillable! Application Form in English
05/01/10
Novartis Patient Assistance Foundation Program
Fillable! Application Form in English
05/01/09
Novo Nordisk Diabetes Patient Assistance Program (formerly Novo-Nordisk Pharmaceuticals, Inc. PAP)
Fillable! Application Form in English
03/01/10
Novo Nordisk Diabetes Patient Assistance Program (formerly Novo-Nordisk Pharmaceuticals, Inc. PAP)
Application Form in Spanish
02/01/09
Novo Nordisk Diabetes Patient Assistance Program (formerly Novo-Nordisk Pharmaceuticals, Inc. PAP)
Application Form for Prandin and Prandimet in English
03/01/10
Novo Nordisk Hormone Therapy Patient Assistance Program
Application Form in English
07/01/08
Novo Nordisk Hormone Therapy Patient Assistance Program
Application Form in Spanish
06/01/08
OcuSoft Patient Assistance Program
Fillable! Application Form in English
Orencia (abatacept) Patient Assistance Program
Application Form in English
01/01/10
Orthovisc Patient Assistance Program
Application Form in English
11/01/09
Pfizer Bridge Program
Application Form for Genoptropin in English
09/01/06
Pfizer Bridge Program
Application Form for Somavert in English
12/01/05
Pfizer Connection to Care
Fillable! Application Form in English
07/01/09
Pfizer Connection to Care
Fillable! Application Form in Spanish
07/01/09
Pfizer MAINTAIN (for people who are recently unemployed)
Application Form in English
05/01/09
Pfizer MAINTAIN (for people who are recently unemployed)
Application Form in Spanish
05/01/09
Pfizer RSVP Program
Application Form in English
07/01/09
Pfizer RSVP Program
Application Form in Spanish
07/01/09
PhosLo Patient Assistance Program
Fillable! Application Form in English
01/01/09
Procrit & Leustatin Patient Assistance Program
Application Form in English
11/01/09
Pulmozyme Access Solutions (formerly Genentech Endowment for Cystic Fibrosis)
Fillable! Application Form in English
Purdue Pharma Patient Assistance Program
Application Form in English
03/01/09
RabAvert Patient Assistance Program
Application Form in English
RapAssist Reimbursement and Patient Assistance Program
Fillable! Application Form in English (Patient Section)
RapAssist Reimbursement and Patient Assistance Program
Application Form in English (Physician Section)
RapAssist Reimbursement and Patient Assistance Program
Application Form in English (Income Verification Section)
RapAssist Reimbursement and Patient Assistance Program
Application Form in English (Provider Prescription Form)
Relistor Patient Assistance Program
Fillable! Application Form in English
Remicade Patient Assistance Program
Application Form in English
11/01/09
Renal Patient Assistance Program (RPAP)
Application Form in English
03/01/10
Retassist Patient Assistance Program (formerly Retavase Solutions PAP)
Application Form in English
08/01/02
Retassist Patient Assistance Program (formerly Retavase Solutions PAP)
Program Brochure in English
01/01/99
Risperdal Patient Assistance Program
Application Form in English
11/01/09
Romark Patient Assistance Program
Fillable! Application Form in English
Romark Patient Assistance Program
Instructions in English
Ross Patient Assistance Program/Abbott Medical Nutritionals Program
Fillable! Application Form in English
03/01/10
Sanofi Pasteur Patient Assistance Program
Fillable! Application Form in English
09/01/08
Sanofi-Aventis Oncology PACT+ (Providing Access to Cancer Therapy)
Fillable! Application Form in English
01/01/09
Sanofi-Aventis U.S. Patient Assistance Program
Fillable! Application Form in English
Sanofi-Aventis U.S. Patient Assistance Program
Instructions in English
Schering-Plough Cares (SP-Cares)
Application Form in English
07/01/07
Schering-Plough Cares (SP-Cares)
Reorder Form in English
07/01/07
Sciele Pharma, Inc. Patient Assistance Program
Fillable! Application Form in English
Sculptra Patient Access Program
Application Form in English
03/01/05
Shire CARES
Fillable! Application Form in English
04/01/10
Solvay Pharmaceuticals, Inc. Patient Assistance Program
Application Form in English
07/01/09
Takeda Patient Assistance Program
Application Form in English
Takeda Patient Assistance Program
Application Form in Spanish
01/01/10
Teva Assistance Program
Application Form in English
06/01/09
The ENcourage Foundation (formerly Wyeth Enliven Services/ENcourage Foundation)
Application Form in English
04/01/10
Torisel Reimbursement Support and Patient Assistance Program
Application Form in English
Touchpoints Patient Assistance Program (formerly VIP3/Vivitrol PAP)
Fillable! Application Form in English
Triax Pharmaceuticals Patient Assistance Program
Fillable! Application Form in English
10/01/09
UCB Patient Assistance Program (formerly Keppra PAP)
Fillable! Application Form for Keppra and Vimpat in English
Valeant Pharmaceuticals International Patient Assistance Program
Fillable! Application Form in English
VELCADE Reimbursement Assistance Program
Fillable! Application Form in English
Venofer Reimbursement Hotline and Patient Assistance Program
Application Form in English
ViroPharma Patient Assistance Program
Application Form in English
01/01/10
Wellspring Patient Assistance Program
Application Form in English
07/01/09
Welvista (formerly CommuniCare)
Application Form in English
Wyeth Oncology Reimbursement Program
Fillable! Application Form in English
Wyeth Pharmaceutical Assistance Foundation Program
Application Form in English
Xigris Treatment Support Program
Fillable! Application Form in English
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