Download and print out an application with instructions

• English*
  [PDF: 1.14 MB, 3 pages]
• Spanish*
   [PDF: 333 KB, 3 pages]

Patients/Consumers:
Patients can call 1-800-727-5400 toll free 8:00 AM–8:00 PM ET to obtain a brochure outlining the program and an enrollment application. The enrollment application must be completed by the patient and his or her physician.

OR

Patients/consumers may request a brochure and application online.

Healthcare Providers/Office Staff:
(Also available to government, social service, or related agencies)
Healthcare providers and their office personnel can call 1-800-994-2111 toll free to obtain enrollment applications for patients and to request additional information about the program.

OR

Healthcare providers/office staff may request patient applications and brochures online.