Pernix Patient Assistance Program

Enrollment



The information you provide below will only be used by the Program Administrator to determine and validate the patient’s program eligibility. Please ensure you have the following documentation ready to upload before proceeding through the enrollment process:

  • The most recent federal tax form(s) confirming applicant's household income
  • Copy of prescription to upload

If at anytime you have questions about your enrollment process, you can contact our Patient Assistance Specialist, Monday through Friday 9:00 a.m.-5:00 p.m. (ET). at 1-800-340-3042.

*If you or any member of your household did not file the most recent tax form(s), please call us for other accepted forms of income documentation.
**Household size is defined to include everyone (including the patient) who contributes to or is dependent on the household income.
About the Patient
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Relationship If Other Than Patient

I am the:

Home Address

Medication Delivery Address   Same as Home Address

The information you provide below will only be used by the Program Administrator to determine and validate the patient’s program eligibility.

If at anytime you have questions about your enrollment process, you can contact our Patient Assistance Specialist, Monday through Friday 9:00 a.m.-5:00 p.m. (ET) at 1-800-340-3042.

Gross annual income for entire household*
(rounded to the nearest dollar):


*Household size is defined to include everyone (including the applicant) who contributes to or is dependent on the household income.

Upload Income Verification Documents

Please upload the most recent year's federal tax return form to verify the patient's income. If you have additional questions, please contact our Patient Assistant Specialist Monday - Friday, 9:00 a.m.-5:00 p.m. (ET).

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This is required for enrollment


Uploaded
If you did not file tax returns last year, please contact our Patient Assistance Specialist Monday - Friday 9:00 a.m.-5:00 p.m. (ET) for acceptable income source documents. Our number is 800-340-3042.

Please provide the information requested below and if any of the questions are not applicable, please indicate that by checking the box. The information you provide below will only be shared with and used by the Program Administrator and the pharmacy staff who will be processing and shipping your prescription.  




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Uploaded

In order to complete your online enrollment, the patient must read and provide their signature on the consent form. Please download, print, read and sign. When complete, scan and upload the signed document into the online enrollment form.

Consent & Release of Information


step 1

Download and print the Consent and Release of Information document

Download Consent Form
step 2


Read the terms and sign the Consent and Release of Information document

step 3

Scan the document in and upload it

Upload signed Consent and Release of Information form

Uploaded


Success! You've completed your enrollment form.

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