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Donnatal PAP Enrollment Form APPLICANT INFORMATION Name Date of Birth Phone Current address City S State Z ZIP Code Where did you hear about the program INCOME INFORMATION IF YOU ARE APPLYING AND ARE ON MEDICARE/MEDICADE YOU DO NOT NEED TO FILL OUT THE INCOME SECTION. List current annual household income below. Indicate the source of your income by checking all boxes that apply. Total annual income Social Security Bene ts Wages Interest/dividends Pension Unemployment Any other sources INSURANCE / COVERAGE INFORMATION Do you have prescription coverage Yes No If yes please check all that apply. Medicare Medicaid State Pharmacy Employer Other if other please list PHYSICIAN / HEALTHCARE PROVIDER INFORMATION Fax Product circle one Elixir Tablets Address DISCLAIMER I UNDERSTAND THAT THE PATIENT ASSISTANCE PROGRAM IS RESERVED FOR INDIVIDUALS THAT REQUIRE FINANCIAL ASSISTANCE TO PURCHASE THEIR MEDICATIONS AND THAT THE SUBMITTAL OF THE INFORMATION REQUESTED ON THIS FORM IS AN APPLICATION FOR CONSIDERATION IN ENROLLMENT IN THE PROGRAM NOT A GUARANTEE OF ACCEPTANCE. Signature of applicant Date The Patient Assistance Program is a service of Revive Pharmaceuticals. Donnatal PAP Enrollment Form APPLICANT INFORMATION Name Date of Birth Phone Current address City S State Z ZIP Code Where did you hear about the program INCOME INFORMATION IF YOU ARE APPLYING AND ARE ON MEDICARE/MEDICADE YOU DO NOT NEED TO FILL OUT THE INCOME SECTION* List current annual household income below. Indicate the source of your income by checking all boxes that apply. Total annual income Social Security Bene ts Wages Interest/dividends Pension Unemployment Any other sources INSURANCE / COVERAGE INFORMATION Do you have prescription coverage Yes No If yes please check all that apply. Medicare Medicaid State Pharmacy Employer Other if other please list PHYSICIAN / HEALTHCARE PROVIDER INFORMATION Fax Product circle one Elixir Tablets Address DISCLAIMER I UNDERSTAND THAT THE PATIENT ASSISTANCE PROGRAM IS RESERVED FOR INDIVIDUALS THAT REQUIRE FINANCIAL ASSISTANCE TO PURCHASE THEIR MEDICATIONS AND THAT THE SUBMITTAL OF THE INFORMATION REQUESTED ON THIS FORM IS AN APPLICATION FOR CONSIDERATION IN ENROLLMENT IN THE PROGRAM NOT A GUARANTEE OF ACCEPTANCE* Signature of applicant Date The Patient Assistance Program is a service of Revive Pharmaceuticals. Donnatal PAP Enrollment Form APPLICANT INFORMATION Name Date of Birth Phone Current address City S State Z ZIP Code Where did you hear about the program INCOME INFORMATION IF YOU ARE APPLYING AND ARE ON MEDICARE/MEDICADE YOU DO NOT NEED TO FILL OUT THE INCOME SECTION* List current annual household income below. Indicate the source of your income by checking all boxes that apply. Total annual income Social Security Bene ts Wages Interest/dividends Pension Unemployment Any other sources INSURANCE / COVERAGE INFORMATION Do you have prescription coverage Yes No If yes please check all that apply. Indicate the source of your income by checking all boxes that apply. Total annual income Social Security Bene ts Wages Interest/dividends Pension Unemployment Any other sources INSURANCE / COVERAGE INFORMATION Do you have prescription coverage Yes No If yes please check all that apply. Medicare Medicaid State Pharmacy Employer Other if other please list PHYSICIAN / HEALTHCARE PROVIDER INFORMATION Fax Product circle one Elixir Tablets Address DISCLAIMER I UNDERSTAND THAT THE PATIENT ASSISTANCE PROGRAM IS RESERVED FOR INDIVIDUALS THAT REQUIRE FINANCIAL ASSISTANCE TO PURCHASE THEIR MEDICATIONS AND THAT THE SUBMITTAL OF THE INFORMATION REQUESTED ON THIS FORM IS AN APPLICATION FOR CONSIDERATION IN ENROLLMENT IN THE PROGRAM NOT A GUARANTEE OF ACCEPTANCE* Signature of applicant Date The Patient Assistance Program is a service of Revive Pharmaceuticals.