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2. 5 Co Payment Online

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

Medical Diagnosis

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• Primary Diagnosis
• Date of Diagnosis

Treatment Plan

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• 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.