Step 1

Patient Services & Support

You hereby authorize Prescription Relief to act on your behalf and to sign applications for the patient assistance programs by hereby granting to Prescription Relief a limited power of attorney for the specific purposes of enrolling you in patient assistance programs with the applicable pharmaceutical companies and any related activities to process your enrollment. You understand this authorization can be revoked at any time by you by providing a signed letter of cancellation to Prescription Relief as described in the fees section. You herby authorize your physician’s office(s) to discuss/release medical information to Prescription Relief relating to your application(s) for patient assistance programs that Prescription Relief is processing on your behalf. You understand that Prescription Relief does not ship, prescribe, purchase, sell, handle, or dispense prescription(s) for patient assistance programs. Prescription Relief is a fee-based mediation advocacy service that assists patients in enrolling in applicable pharmaceutical companies’ patient assistance programs. The medications themselves are offered by the pharmaceutical companies through their patient assistance programs at no cost to the eligible applicant. You also understand and acknowledge that it is each individual pharmaceutical company who makes the final decision as to whether you qualify for their assistance program(s). You understand Prescription Relief reserves the right to rescind, revoke, or amend, its services at any time. Prescription Relief does not guarantee your approval for patient assistance programs; it is up to each applicable drug manufacturer to make the eligibility determination. Each drug manufacturer independently sets its own eligibility criteria and determines which products are include in their assistant programs. Medications covered are subject to change at any time. Prescription Relief assembles and submits your application to the pharmaceutical company but does not participate in the review process to determine which applicants are eligible.

Eligibility for Assistance

You are experiencing hardship in affording your medication and/or you currently do not have coverage that reimburses or pays for your prescription medications. You affirm that the information provided on this form is complete and accurate. If you determine the information was not correct at the time you provided it to Prescription Relief, or if the information was accurate but is no longer accurate, you will immediately notify Prescription Relief in writing by providing the correct information.

Guarantee of Refund(s)

If you are determined to be ineligible for all patient assistance programs and you have a letter of denial from each applicable drug manufacturer, Prescription Relief will refund the first month service fee(s) for the medication(s) determined to be ineligible. Prescription Relief requires proof of denial via a copy of the denial letter received from the applicable drug manufacturer explaining why you were ineligible and a letter of cancellation from the patient.

Patient Support Fees

During the initial enrollment process if we find we are unable to assist you with at least one medication, there will only be an enrollment fee charged for administration services. The initial fee plus the first month premium will be debited upon enrollment. The subsequent subscription charges will be billed on the 5th, 15th, or the 25th of each month following your enrollment and receipt of this form. You will be notified by phone for the medication(s) for which we are able to assist you with. There are no other costs associated with this program. It will take approximately 4-6 weeks from signing this form to start receiving your first supply of medication(s). This range is an average amount of time and is contingent upon prompt response to the information we request from you and your physician(s). The medication(s) is shipped directly from the pharmaceutical companies and delivered either to your home or physician’s office, depending upon the manufacturer delivery guidelines. You hereby acknowledge that you are not paying for medication(s) through Prescription Relief service; rather you are paying for the administrative service of ordering, managing, tracking, and refilling medications received through Prescription Relief and/or its agents to debit the account provided on the front of this form for all administrative fees described in this Fee section. You also agree to pay any associated fees should your EFT (electronic funds transfer) be returned unpaid by your financial institution. Due to the service-based nature of the Prescription Relief service, there are no refunds other than what is explained in the Prescription Relief Guarantee below. You hereby acknowledge, consent and agree this agreement is for (12) months commencing on the date you sign below and will automatically be renewed for (12) month terms thereafter. You may terminate this agreement at any time by providing a signed letter of cancellation. Cancellations will take up to 30 days to process. Upon termination you agree to be financially responsible for any outstanding balances. This monthly transaction will appear on your billing statement as “Prescription Relief” and “Find Advocate Solutions”. You agree that you may be contacted via telephone, cellular phone, text message, or email through all numbers/addresses and/or automated dialing service by Prescription Relief or affiliates. By signing below, you further agree to release Prescription Relief and Find Advocate Solutions, its agents, employees, and successors and assigns harmless against any and all damages including legal fees and cost arising from third persons ingesting any medication procured for you through the Prescription Relief advocacy program.

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