Patient Aid Application

Patient Aid Form

Download the Patient Aid/Prescription Claim Form PDF

Patient Aid Claim Form

Prescription Claim Form PDF
(For patients who've already submitted the original package)

CHILDREN’S LEUKEMIA RESEARCH ASSOCIATION CO-PAY ASSISTANCE PROGRAM

APPLICATION INSTRUCTIONS

Please read our Patient Aid Summary page in its entirety and all related pages prior to submitting your application.

Applications may be scanned, faxed, or mailed. Applications will not be processed if any information is missing.

  • Attach a copy of your health insurance I.D. card(s).
  • Make a copy of the application for your records.
  • Medical care providers/treating facilities must complete page 2 of the application and forward it in any of the methods listed above.

We can only apply first-come/first-serve basis to applications after all completed pages have been received. In the event additional information is required, you will be contacted. Please allow up to 30 days for properly completed application to be approved and processed

A new application is required each year for further assistance.

Please feel free to contact us via email with any questions you may have: Phone: 516-222-1944 | Fax: 516-222-0457 *All information is confidential and HIPAA compliant*

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