2021 Patient Aid Program Application Instructions

• You will need to create a free Submittable account or sign in with Google or Facebook credentials in order to submit to these forms.
• You can save a draft of your work if you would like to finish filling out the form at a later date.
• If you need to make changes to your form, please withdraw your submission and resubmit.
• If anything changes with the information you submitted, please request to edit the submission
• Our platform works best on Google Chrome, Firefox, and Safari. Internet Explorer is not supported. Please make sure you are using a supported browser.
• Please be sure to whitelist notification emails from Submittable and check the email you used to sign up for your Submittable Account regularly. Check out the Submitter Resource Center or reach out to Submittable's Customer Support team with any technical questions here.
• You will need to provide an email address for your medical provider/treating physician and a copy of your insurance card.