Program Applications

Tips for using the applications:

  • You will need Adobe Reader to open the applications. Download this free program or the latest version, which is recommended.
  • Click the button in the top right of the application to turn on the Highlight Fields Option which will highlight the fields to be filled out.
  • Use the "tab" key to easily go to the next field.

As of 04/24/2014 there are 639 applications available.

Click on the first letter of the name of the program. Then click on the application for that program. Dates next to each listing reflect the last update. Some applications may need to be opened with a different viewer depending on which browser you are using. Firefox users may get a message saying "This PDF document might not be displayed correctly." Try clicking on the "Open With Different Viewer" option. If you are still unable to interactively complete the application, use a different browser.

Send the completed application to the address on the application and not to NeedyMeds.

If you cannot find an application or are having trouble printing one, contact the program or company.

Contact NeedyMeds if you find any content errors.

For link problems or other technical problems, send an email to webmaster.

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AbbVie Patient Assistance Foundation 04/14/14
AbbVie Patient Assistance Foundation for Androgel 04/14/14
AbbVie Patient Assistance Foundation for Creon 04/14/14
AbbVie Patient Assistance Foundation for HUMIRA 04/14/14
AbbVie Patient Assistance Foundation for Lupron Depot 04/14/14
AbbVie Patient Assistance Foundation for Marinol 02/19/14
AbbVie Patient Assistance Foundation for Norvir and Kaletra 04/14/14
AbbVie Patient Assistance Foundation for Zemplar 04/14/14
ACT Program Enrollment Form 03/13/14
ACT Program Enrollment Form (Spanish) 03/13/14
Actavis Patient Assistance Program Application for Gelnique 03/05/14
Actavis Patient Assistance Program Application Form for Infed, Rapaflo, and Trelstar 03/06/14
Acthar Support & Access Program 02/12/14
Adempas Patient Enrollment and Consent Form 01/22/14
Adempas Prescriber Enrollment and Agreement Form 01/22/14
Afinitor Co-Pay Support Program: Contact program
Akrimax Patient Assistance Program Enrollment Form 02/11/14
Alcon Cares, Inc. Application 03/14/14
Alexion Complement Foundation: Contact program
Allergan Patient Assistance Program 01/21/14
Alpha-1 AATmosphere Program Enrollment Form 02/19/14
Alphanate Natural Choice Free Trial Offer Enrollment Form 03/10/14
Alphanate Sample Request Form 04/01/14
AlphaNine SD Sample Request Form 03/10/14
AlphaNine SD Savings Card Program Brochure: Contact program.
AMAG Assist Enrollment Form 02/24/14
Amedra Cares Patient Assistance Program 04/03/14
American Regent Patient Assistance Program (Injectafer) Application 04/18/14
American Regent Patient Assistance Program (Injectafer) Request Form 04/18/14
American Regent Patient Assistance Program (Venofer) Application 04/18/14
American Regent Patient Assistance Program (Venofer) Request Form 04/18/14
Amgen FIRST STEP Co-Pay Support: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 03/31/14
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 03/31/14
Angiomax Reimbursement and Patient Financial Assistance Program Application 03/20/14
Apidra No Copay Savings Card: Contact program
Apligraf Patient Assistance Program 03/06/14
Apokyn Co-Pay Assistance Access Guide 02/20/14
Apokyn Patient Assistance Program Enrollment Form 02/20/14
Apokyn Staement of Medical Necessity 02/20/14
Apokyn Staement of Medical Necessity for VA 02/20/14
Aptalis Zenpep Patient Assistance Program Application 04/03/14
Arbor Gliadel Wafer Patient Assistance Program Application 04/04/14
Arbor Patient Assistance Program Application 04/04/14
Arch Foundation Patient Assistance Program for Mirena 04/07/14
Arch Foundation Patient Assistance Program for Mirena (Spanish) 04/07/14
Ariad PASS Prescriber Enrollment Form 02/12/14
Ariad PASS Prescriber Enrollment Form (Spanish) 02/12/14
Assure Access Program Enrollment Form 02/14/14
Astellas Access Program (PROGRAF): Contact program
Astellas Access Program (PROTOPIC): Contact program
Astellas Access Program (VESICARE and MYRBETRIQ): Contact program
Astellas Access Program (XTANDI): Contact program
Astellas Access Program for ASTAGRAF XL: Contact program
Astellas Stock Replacement Program For AmBisome: Contact program
Astellas Stock Replacement Program For Lexiscan: Contact program
Astellas Stock Replacement Program For MYCAMINE: Contact program
Astellas Stock Replacement Program for VAPRISOL: Contact program
AstraZeneca Cancer Support Network 04/03/14
AstraZeneca Cancer Support Network (Spanish) 04/03/14
Atripla Patient Assistance Program 02/17/14
Aubagio One to One Co-Pay Program: Contact program
Auxilium Patient Assistance Program 04/08/14
Axona Patient Assistance Program Application 02/28/14
AZ&Me Prescription Savings Program with Med D 01/24/14
AZ&Me Prescription Savings Program with out Med D 01/22/14
Azilect Patient Assistance Program 01/24/14
Azilect Patient Assistance Program (Spanish) 01/24/14