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 12/14/2017 there are 614 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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R-Pharm US Access and Support Program Enrollment Form 03/20/17
R-Pharm US Access and Support Program Enrollment Form (Spanish) 03/20/17
R-Pharm US Access and Support Program Patient Authorization Form 03/20/17
R-Pharm US Access and Support Program Patient Authorization Form (Spanish) 03/20/17
Ranexa Connect Patient Assistance Program Enrollment Form 05/19/17
Rasuvo Disposal Program: Contact program
Rayaldee Patient Assistance Program Application (PAP) 03/20/17
Rayaldee Patient Assistance Program Application (PAP) Spanish 03/21/17
Rayaldee Service Request Form (SRF) 12/15/16
REACH Program Enrollment Form 03/23/17
Recordati Reimbursement Hotline: Contact program
Reimbursement Support Form and Prescription for Qutenza 04/24/17
RELiZORB Patient Assistance Program Enrollment Form 07/21/17
RELiZORB Patient Assistance Program Order Form 07/21/17
RELiZORB Patient Guide 07/21/17
Repatha Free Needle-Disposal Container Program: Contact program
Romark Laboratories Patient Assistance Program for Alinia Enrollment Form: Contact program
Rubraca Connections Patient Brochure 07/21/17
Rubraca Connections Prescription Form 07/21/17
Ruconest Solutions Patient Authorization Form 07/12/17
Ruconest Solutions Patient Brochure 07/12/17
Ruconest Solutions Patient Consent Form 07/12/17
Ruconest Solutions Patient Enrollment Form 07/12/17
Rx Outreach Application 10/03/17
Rx Outreach Diabetic Supplies Order Form (Prodigy) 10/03/17
Rx Outreach Medication List 10/03/17
Rx Outreach Refills and New Prescription Form 10/03/17

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