Information required for applications

The following information is required to complete an application for TotalAssist financial assistance.

Patient demographic information

• First and last name
• Social Security Number or Alien Number
• Date of birth
• Email address
• Mailing address
• Phone number
• Gender
• Ethnicity
• Marital status
• Veteran status
• Employment status
• Financial information: annual household income
• Number in household

Patient household and income

• Whether or not the patient filed (or will file) a U.S. tax return for the most current year
• Has the patient’s annual income changed significantly from last year?
• Used for pre-screening only:
  • Annual household income, household size, state of residence 

Authorized person(s)

• Is anyone else authorized to speak with us (Patient Advocate Foundation) on behalf of the patient? 
• Include their name, relationship, special authorization, and phone number

Patient insurance Information

• Primary insurance carrier
• Carrier phone number 
• Insurance and plan type
• Policy ID and group number 
• Subscriber’s name and date of birth
• Copay or coinsurance amount for medical services
• Copay or coinsurance for pharmacy benefits
• Does the patient have Medicare Part D?
• Does the patient have a Medicare supplement? Do they have secondary insurance?
• Is insurance coverage continuation under COBRA in effect?
• Does this plan cover prescription drugs at the pharmacy and provider office?

Treating provider information 

• Provider name
• Facility name
• Address
• Phone and fax numbers
• Office contact name and email address if known 

Medical diagnosis

• Primary diagnosis
• Date of diagnosis (If within 6 months, exact date. If prior to 6 months ago, month/year at minimum)

Confirmation of treatment plan

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

Patients

No, you won’t be asked to submit any documents with your application. We will reach out to your provider to verify diagnosis and treatment plan. However, in come cases, we may reach out to you (the patient) to verify your income eligibility. Learn more about income verification.

Providers

When you apply on behalf of patients, we will ask that you attest to the accuracy of the diagnosis and treatment plan. Learn more about diagnosis verification.

Pharmacies

When you apply on behalf of patients, we will ask that you attest to the accuracy of the diagnosis and treatment plan and submit documentation confirming diagnosis and treatment plan. Get the details about diagnosis verification. 

• Patients and caregivers
• Providers
• Pharmacies
• Nonprofits