American Patient Assistance

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Information About Your Privacy

APA does not disclose your name or contact information to third parties for quoting purposes. APA does not under any circumstances sell or otherwise disclose your name, contact information, or medical information to any third parties besides the pharmacy or pharmaceutical manufacturer we order your medication from explicitly for the purpose of placing your order and only in complete compliance with the Health Insurance Portability and Accountability Act.

For more information about APA and HIPPA compliance, please read our HIPPA information page.

First Name:
MI:
Last Name:
Home Phone:
Cell Phone:
Email Address:
Best Time to Call:	AM: PM: Anytime:
State of Residence:
Do you currently have prescription insurance? (Insurance, not a Discount Card)	Yes: No:
Do you have Medicare "D"?	Yes: No:
If Yes, are you in the Medicare "D" Gap (Donut Hole)?	Yes: No:
Do you have any form of Medicaid?	Yes: No:
How many people live in your household (excluding renters)?
What is the gross income of all members of your household combined (excluding renters)? Do not be afraid to apply if your gross income is slightly higher than these values, you may qualify under other circumstances.	$25,000 or less: $25,001 to $31,000: $31,001 to $36,000: $36,001 or more:
List ALL of Your Medications Here (excluding over-the-counter medications): Please list the medication, strength, dosage, and current cost to you per month for each medication. Example: Allegra 180mg, 1 dose per day, $50/month
If you have a brochure or other marketing material with a Reference Code, please input that here: