Patient Co Payment

| Posted on by



Patient Advocate Foundation's Co-Pay Relief program exists to help reduce the financial distress patients, and their families face when paying for treatment. We believe that no patient should go without life changing medications because they cannot afford. Your outstanding patients deserve an outstanding payment experience. Patientco technology creates a superior patient payment experience, delivering meaningful financial results for Health Systems.

Required Information to Complete an Application for Assistance:

Patient Demographic Information

  • First & Last Name
  • Address & Phone Number
  • Gender, Ethnicity & Marital Status
  • Veteran Status, Employment Status, Date of Birth
  • Social Security Number or Alien Number
  • Financial Information
  • Number in Household

Annual Household Income

  • Do you file a Tax Return for the most current year?
  • Has your Annual Income changed significantly from last year?

Authorized Person

  • Is anyone else authorized to speak with CPR on the Patient’s behalf?
  • If yes, the following fields are required: First Name, Last Name, Relationship, Special Authorization, Phone
    Number

Insurance Information

  • Primary Insurance Carrier Insurance & Plan Type Policy ID & Group Number Telephone Number
  • Subscriber’s Name and Date of Birth
  • Co-Pay or Coinsurance for medical services
  • Co-Pay or Coinsurance for pharmacy benefits
  • Do you have Medicare Part D?
  • Does the patient have a Medicare Supplement? Do you have Secondary Insurance?
  • Is Insurance coverage continuation under COBRA in effect?
  • Does this plan cover prescription drugs at the pharmacy and provider office?

Treating Physician Information

  • Physician Name Facility Name Physical Address
  • Phone and Fax Number
  • Office Contact Name and Email Address, if known

Gopatientco Pay My Bill Online

Medical Diagnosis

  • Primary Diagnosis
  • Date of Diagnosis

Treatment Plan

  • Confirmation you have a treatment plan and are currently in treatment, have been in treatment in the last 6 months or will begin treatment in the next 60 days.

Financial Assistance Program

Patient

Helps with treatment-related costs, such as transportation, home care and child care. View available assistance and eligibility guidelines.

Learn more

Patient Co Payment Pbs

Co-Payment Assistance Foundation

Helps people with cancer overcome financial access and treatment barriers by assisting them with co-payments for their prescribed treatments. View covered diagnoses and eligibility guidelines.

Learn more

Helping Hand Online Financial Resource Database

Find additional local and national resources to help with financial and practical needs in our searchable database.

Search Now