Freddie Financial Assistance Program Application
Please complete the following application to determine if you are eligible to receive support from the Freddie Financial Assistance Program.
Patient Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
*
Please Select
Phone
Email
Email
*
Please enter a valid email address.
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Annual Household Income
*
Please Select
$0 - $35,000
$35,001 - $75,000
$75,001 - $100,000
$100,000+
Status
*
Please Select
Canadian
Permanent-Resident
Non-Resident
Prescriber (Doctor/Clinician) & Clinic Information
Clinic Name
*
Please Select
Freddie
Other
Specify Clinic Name
*
Prescriber Name
*
First Name
Last Name
Clinic Phone Number
*
Please enter a valid phone number.
Clinic Fax Number
*
Please enter a valid fax number.
Clinic Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Medication
Prescribed Medication
*
Please Select
Emtricitabine-Tenofovir
Descovy
Prescription Date
*
-
Month
-
Day
Year
Date (must match original prescription date)
Quantity Prescribed
*
Manufacturer
*
Please Select
Apotex
Mylan
Pharmascience
Gilead
Other
Specify Manufacturer
*
Insurance Information
Insurance Type
*
Public Plan
Private Plan
Both
None
Province
*
Please Select
Alberta
British Columbia
Manitoba
Ontario
Saskatchewan
Does your private plan have a yearly maximum of $10,000 or less?
*
Yes
No
Primary Private Plan
*
I need help from PurposeMed Reimbursement Services regarding financial assistance, and I would like to be contacted by a PurposeMed Reimbursement Specialist
*
Yes
No
Have you applied to the Trillium Drug Program?
*
Yes
No
Have you enrolled in the MAX Gilead Patient Support Program?
*
Yes
No
MAX Gilead Patient Support Program
*
Pharmacy Information
Please enter the details of the pharmacy where you received your prescription.
Pharmacy Name
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Financial Assistance Amount
The dollar figures ($CAD) entered below must match your submitted original prescription receipt. The amount eligible for financial assistance is the amount you paid to the pharmacy (deductible).
Medication Costs
*
Upload Official Original Prescription Receipt(s) and Payment Receipt(s) (Required)
*
Browse Files
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Authorization
Patient Signature
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