How to Apply

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.

 

 

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Copyright 2019 · Exemplar Physicians Clinical Management Services

 Exemplar Physicians Clinical Management Services

1107 West Market Center Drive

High Point, NC 27260

(844) 451-8899

Proud Partner of

Exemplar Healthcare Partnership Organization