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 03/20/2018 there are 594 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.
Egrifta Assist Statement of Medical Necessity (Spanish)
Eisai Assistance Halven $0 Co-Pay Program Enrollment Form 12/19/17
Eisai Assistance Program (Belviq) Enrollment Application Provided by Rx Outreach 12/29/17
Eisai Assistance Program Enrollment Form 12/29/17
Eisai Assistance Program Insurance Verification Form 12/19/17
Eisai Banzel Patient Assistance Program Application Provided by Rx Outreach 12/29/17
Eisai Fycompa CIII Patient Assistance Program Application 02/06/18
Eisai Fycompa CIII Patient Assistance Program Safety Information 12/29/17
Eisai Lenvima Intake Form 12/29/17
Eligard Patient Assistance Program: Contact program
EmflazaCares Prescription Start Form
Endo Patient Assistance Program for Nascobal Application 02/20/17
Endo Pharmaceuticals Patient Assistance Program: Contact program
Enfamil EnfaCare Drive to Thrive Program: Contact program
Entereg Healthcare Provider Letter 02/22/18
Entereg Hospital E.A.S.E. Registration Form 02/22/18
Entereg Prescriber and Pharmacist Information Brochure 02/22/18
Entyvio Co-Pay Assistance and Nurse Support Enrollment Form
Entyvio Connect Benefit Investigation Enrollment Form 02/12/18
Envarsus XR Patient Education Brochure 02/22/18
Envarsus XR Patient Education Brochure (Spanish) 02/22/18
EpiPen4Schools Program Free Certification Form
EpiPen4Schools Program Replenishment Certification Form
EpiPen4Schools Program Standing Order Protocol Form
Episil Direct Order Form 03/16/18
Episil Patient Brochure 03/16/18
Equetro Patient Assistance Program Enrollment Form 01/23/18
EstroGel Sample Request Form for Healthcare Professionals Only
Eucrisa Savings Support Program Enrollment Form: Contact program
Exelixis Access Services (EASE) Patient Assistance Program Authorization Form 01/26/18
Exelixis Access Services (EASE) Patient Assistance Program Enrollment Form
Extavia Go Program: Contact program
EYLEA4U Enrollment Form 01/29/18
EYLEA4U Enrollment Form (Spanish) 01/29/18