TBD Health - Free HIV Copay Assistance
TBD Health offers comprehensive support for individuals living with HIV including providing significant copay assistance. To learn more and see if you qualify, please fill out the form below and our care team will be in touch during business hours (M-F).
Please provide your Legal Name
*
First Name
Middle Name
Last Name
Do you have a preferred name other than your Legal Name?
Please provide an email address where we can reach you
*
Please enter a valid phone number. By submitting this form, you consent to TBD Health contacting you via email.
Please provide a Phone Number where we can reach you
*
Please enter a valid phone number. By submitting this form, you consent to TBD Health contacting you via phone.
What is your Date of Birth
*
-
Year
-
Month
Day
Date
What is your Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have health insurance? Note: We can only accept prviate insurance as part of our program right now.
*
Yes
No
What kind of health insurance plan do you have?
*
Upload screenshots of the Front AND Back of your insurance card
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Is there anything else you'd like us to know?
How did you find out this Program?
Now, for the legal formalities. Please read our Terms of Service, Privacy Policy and Telehealth Consent. Please sign below if you understand and accept.
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