Program Enrollment Application

The Assistance Fund's (TAF's) compliance program prohibits TAF from communicating with donors or those acting on behalf of donors about patient accounts. Effective February 17, 2020, TAF will not accept applications submitted by hubs or reimbursement service providers on behalf of patients. If you would like to refer your patient to TAF, please CLICK HERE and complete the patient referral information.

Please provide the following information about the patient being enrolled:

Is the patient a citizen or permanent resident of the United States of America?

YesNo

At this time the patient must be a U.S. citizen to be eligible for enrollment.

I certify that the patient has been diagnosed with the disease state(s) covered by the program(s) for which they are applying for.

YesNo

Is the patient in the process of completing genetic testing for the disease state(s) for which they are applying for?

YesNo

The patient may not receive additional financial support unless the patient is diagnosed with the disease state(s) covered by the program and can provide evidence of such diagnosis.

At this time, the patient must be diagnosed with the disease state(s) covered by the program or in the process of completing genetic testing for the disease state(s) for which they are applying for.

Patient First Name

Patient Last Name

Patient Date of Birth

mm/dd/yyyy (enter all 4 digits for year)

Patient Primary Phone Number

000-000-0000

Primary Phone Type