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How to Fax a Patient Assistance Program Application

Pharmaceutical patient assistance programs give free or reduced-cost medication to people who cannot afford a prescription. Almost every one of them takes applications by fax, because the patient section, the prescriber section and the proof of income have to arrive together as one package. A missing page puts the whole application on hold.

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Why These Programs Use Fax

A patient assistance application has three parts from two people. You complete and sign the patient section and attach proof of income. Your doctor completes and signs the prescriber section, which doubles as the prescription. If the practice also needs to send medical records separately, that is a different fax to a different number. The program needs all of it in one place before it can start. Fax keeps the package together and gives both of you a timestamped record that it arrived.

Pfizer's form warns that missing information or consents may cause delays, and AstraZeneca's says both the patient form and the provider form must be received to determine eligibility.

The Fax Numbers

Each manufacturer runs its own program with its own number, printed on the current application form. Take it from the form itself, not from a forum, because programs change contractors and numbers move.

Pfizer Patient Assistance Program: use the fax on your medicine's form
AstraZeneca AZ&Me: 877-239-0867
Bausch Health PAP: 844-705-0160
Confirm each on the manufacturer's own site before sending. Pfizer's fax numbers differ by program: for example, the Pfizer Oncology Together form prints 1-877-736-6506 and the Velsipity form prints 1-646-862-9655.

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What Goes in the Package

The patient application, signed and dated. Proof of household income: most recent federal return, W-2s, or recent pay stubs. The prescriber section, signed by the doctor, with the diagnosis and the prescription. Some programs also want proof of insurance denial or a Medicaid determination, the same documents that go with hardship forms and SNAP recertification. Read the form's checklist; what it asks for is what delays the application if it is missing.

A complete package is typically four to eight pages, inside the $1.00 price. For how that compares with a copy shop or a monthly plan, see the cheapest way to send a fax.

Who Sends It

Either you or the doctor's office. Many practices fax these for patients as a courtesy; many do not, and the patient is left to do it. AstraZeneca's form notes it can be faxed from the provider's office. If you are sending it yourself, make sure you have the prescriber page back from the doctor, signed, before you start. Most people do this from a phone; the iPhone and Android guides cover photographing each page so it transmits cleanly.

After It Arrives

Review time varies by program. Medication ships to your home or to the doctor's office, depending on what the form specifies. If you hear nothing in a month, call the program's phone line with your confirmation email to hand.

Why send it here

One dollar for up to ten pages. Nothing more, and nothing that renews.

Nothing is printed on your document. It arrives exactly as you uploaded it.

If it cannot be delivered, the money goes back to your card without you asking.

No account, no password, no card kept on file. Upload, type the number, pay.

Frequently Asked Questions

Cost and what you get
How much does it cost to fax a patient assistance application?
$1.00 for up to 10 pages, which covers a complete application with income documents. No account, no subscription, and nothing printed on the pages.
Can I fax a patient assistance application for free?
Free services cap you at three pages, and a complete application with income proof and the prescriber section runs longer than that. Several free services also print their own advertising across the cover page. On a medical application that is not where you want it.
Is there a catch at $1.00 for a patient assistance fax?
No. Ten pages, no account, no card kept on file, nothing that renews. If the fax cannot be delivered the money goes back automatically.
Sending a fax
Does my doctor have to sign it?
Yes. The prescriber section is the prescription, and the program will not process an application without it. Signature rules vary by program: Pfizer’s form says no stamps, AZ&Me requires a wet signature, and Bausch Health accepts electronic and stamped signatures except for controlled substances.
What happens if a page is missing?
The application is put on hold until the missing information arrives, and nobody calls to tell you. Use the checklist on the form, count your pages before sending, and put your name on every one.
How long does approval take?
It varies by program. Bausch Health, for example, says processing time varies based on completeness, and AZ&Me says a decision on its online application may be made immediately. If you hear nothing in a month, call the program’s phone line with your confirmation email, which records exactly when your fax was accepted.
Do I need an account to send this?
No. Upload the signed pages, type the program’s fax number, and pay. There is no sign-up and no password. The only thing we ask for is an email address for your confirmation.
Is my medical information stored after sending?
No. The document is deleted from the servers once the fax has gone. There is no account and no archive. You keep your own copy and the confirmation email.
Fax numbers and format
What is the Pfizer Patient Assistance Program fax number?
It depends on the medicine, because Pfizer's forms print different fax numbers. For example, the Pfizer Oncology Together form prints 1-877-736-6506 and the Velsipity form prints 1-646-862-9655. Pfizer RxPathways does not publish a fax online, so use the number on your own application or call 1-844-989-7284 before sending.
What is the AstraZeneca AZ&Me fax number?
877-239-0867 on the current application form. Confirm it on AstraZeneca’s AZ&Me site before sending.
What is the Bausch Health patient assistance fax number?
844-705-0160 on the current form. Confirm it on Bausch Health’s site before sending.
Receiving a reply
Will the program fax anything back?
Usually not; approvals come by mail or phone. If a program needs to fax you, our sister service GetAFax.com provides a number for $5 for 24 hours, with anything received arriving in your email as a PDF.
Delivery, proof and safety
What proof of income do I need?
Most programs accept your most recent federal tax return, W-2 forms, or recent pay stubs. Pfizer's Oncology Together form lists those three, or an electronic income check if you sign its consent section, while AZ&Me does not list income documents and can estimate income from credit and other data. Send what the form asks for; sending something different is the most common reason an application stalls.
What if my fax to the program fails?
You are refunded automatically and you get an email explaining what happened. Retrying costs nothing.
More questions
What is a patient assistance program?
A program run by a drug manufacturer that provides its medication free or at reduced cost to people who cannot afford it. Pfizer, AstraZeneca, Bausch Health, Lilly, Merck and most others run one. Eligibility is based on household income, with limits set by each program (Bausch Health’s, for example, is 300 percent of the federal poverty level), and on having a prescription for one of their products.
Why do patient assistance programs use fax?
Because the application has three parts from two people: the patient section, the prescriber section and the proof of income. Fax keeps them together as one package with a timestamp. AstraZeneca's form, for example, says both the patient form and the provider form must be received to determine eligibility.
Can my doctor fax it for me?
Yes, and many practices do. AstraZeneca’s form notes it can be sent from the provider’s office. If your practice does not, you can fax the complete package yourself once you have the signed prescriber page back.
Does this page tell me whether I qualify?
No. Eligibility rules are set by each manufacturer and change. This page covers how to get the application there intact and on record. The program’s own site decides who qualifies.

Send it for $1.00, with nothing printed on it

Up to 10 pages to any US or Canada number. No account, no subscription, and an automatic refund if it cannot be delivered.

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