To apply for the Patient Assistance Program, complete the form below. An advocate will contact you to initiate the process and obtain additional information to determine eligibility. A care management fee is collected if the patient is eligible. When forms are received back from the patient, the provider is contacted for a prescription.
Enrollment packet is forwarded to manufacturer for processing.
The patient will receive a 90 day supply of medication by shipment directly to their home address or to the provider’s office.
Medication will be reordered for the patient by Exemplar in 90 day increments.
Copyright 2019 · Exemplar Physicians Clinical Management Services
Exemplar Physicians Clinical Management Services
1107 West Market Center Drive
High Point, NC 27260
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