Home  |  First Time Users  |  Advocates  |  Common Questions  |  PAPTracker  |  About Us   

Program Information

Please complete all the information on this form so we can enter your program into our database.

Program Name 
Address Line 

Address Line 

City, State and ZIP 
  
Local Phone 

Toll Free Phone 

Fax 
E-mail 

Website 

Hours/Days of Service 
Who You Help (Be specific) 
How You Help (Be specific) 
Geographic Area Serviced 
Services You Provide 
Eligibility Criteria 
How to Apply 
Is your organization non-profit?  Non-ProfitFor-Profit
Do you charge a fee?  YesNo If yes, how much?
Languages 

This following information is for our files only and will not appear on the website

Please check one or more of these descriptions to help us categorize your program:
  This program or foundation is based on a specific disease, assists patients with health-related expenses (including financial grants, insurance copays, purchase of some health-related goods or other assistance with expenses)
  This program helps patients find and apply for Patient Assistance Programs and other types of assistance.
  This program is funded and administered by the state.
  This is a Free Clinic that provides direct medical, dental or mental health services at little or no charge or on a predefined sliding scale.
Contact Person 
Position/Title 
Contact's Phone 
Contact's Fax 
Contact's Email 
Contact's Address
(if different from above) 
Other Comments 
 




Copyright ©2012 by NeedyMeds, Inc.
Contents may not be reproduced in any form
except for personal use
and may not be used on any other website without permission.

NeedyMeds makes every effort to ensure the accuracy of the information on the website.
However, we can't guarantee the accuracy or completeness of the information.
Always check with the individual program if you have questions.