Patient assistance program applications by fax: forms, proof, hardship

A patient assistance program application goes on the program's own form: a patient section, a prescriber section with signature, the income or hardship proof it asks for and the route it names. AZ&Me, Sanofi Patient Connection and the Genentech Patient Foundation take it by fax; each program sets eligibility, often 300% or 400% of the federal poverty level.

How do you apply to a patient assistance program by fax?

A prescriber's office applies to a patient assistance program by completing the program's own application, adding the proof the program asks for and sending it by the route the program names, which is fax at some programs, mail at others and online at NovoCare. The table sets the programs side by side, and Not stated means the program's page is silent.

Who is eligible, and how do programs measure income?

Each patient assistance program sets its own eligibility, often household income as a share of the federal poverty level together with the patient's insurance status. HHS ASPE sets the 2026 poverty guidelines for the 48 contiguous states and the District of Columbia at $15,960 for one person, $21,640 for two, $27,320 for three and $33,000 for four, rising to $55,720 for eight, with $5,680 added for each person beyond eight. A program that sets its limit at 300% or 400% applies that share to the guideline for the household's size.

A second table lists each program's income test and insurance condition as its own page states them.

What goes in the application, and who signs it?

A patient assistance program application has a patient part and a prescriber part, and each program names its signers. Merck's enrollment form must be signed by the patient and the physician or prescriber, the Genentech Patient Foundation requires both a Patient Consent Form and a Prescriber Foundation Form, and Pfizer RxPathways has the patient and the healthcare provider submit a completed enrollment form.

What proof of income or hardship letter do programs accept?

Patient assistance programs accept the proof their own pages list: Pfizer RxPathways lists income proof such as a W2 form, a paycheck stub or the prior year's tax return, and NovoCare lists documents such as the last 3 paystubs, a W2 or a 1099 for patients who did not file taxes or had a life event affecting their income. Merck's Patient Assistance Program says additional supporting documentation is not required at this time.

A hardship request appears on Merck's JANUVIA page: a patient who does not meet the insurance coverage criteria, whose income meets the program criteria and who has special circumstances of financial and medical hardship can request an exception. The program's own form or page sets what a hardship request must contain.

Where do you send it, and how long does a decision take?

A patient assistance program application goes to the fax number or address printed on the program's current form, and the programs that state a decision time give 2-4 business days at AZ&Me, usually 5-7 business days at Sanofi Patient Connection and 5 business days at the Genentech Patient Foundation. AZ&Me's 2-4 business days cover a decision or a request for more information on a faxed or incomplete application, the Genentech Patient Foundation's 5 business days start once it has both required forms, and Sanofi Patient Connection's 5-7 business days apply to fully completed and signed applications.

Merck's pages name different routes for the Merck Patient Assistance Program: the JANUVIA page lists fax, online enrollment and mail, and the FAQ page calls it a mail-in program, so the practice confirms the route on the form it holds. Merck's FAQ page calls only the Merck Vaccine Patient Assistance Program a fax-in program.

What options do Medicare Part D enrollees have?

Medicare Part D enrollees can apply for Extra Help through Social Security, check a State Pharmaceutical Assistance Program or ask a drug maker's program whether it takes Part D enrollees, and each manufacturer program sets its own Part D rules.

• Extra Help. Social Security says the Extra Help program helps people with limited income and resources lower or cut Part D costs, and people can apply any time before or after they enroll in Part D. Medicare.gov lists the 2026 limits as $23,940 of income and $18,090 of resources for an individual, and $32,460 of income and $36,100 of resources for a married couple.
• State Pharmaceutical Assistance Programs. Medicare.gov says these programs provide coverage from a state, or the U.S. Virgin Islands, to help pay drug plan premiums, cost sharing or both, that contributions may count toward the Medicare drug coverage out-of-pocket limit, and that eligibility depends on each program's rules.
• Manufacturer programs. Medicare.gov says some pharmaceutical companies offer programs for people enrolled in Part D, with different eligibility requirements at each company. AZ&Me requires that a Medicare beneficiary not be eligible for or enrolled in Extra Help, Merck ends enrollment at the end of the calendar year for patients with Part D, and the Amgen Safety Net Foundation lists, for certain products, a qualifying Medicare patient with an affordability gap and no access to Extra Help or independent copay foundation funding.
• HHS-OIG on programs and Part D. HHS-OIG says in its November 2005 news release on its Special Advisory Bulletin that a drugmaker using a patient assistance program it operates or controls to subsidize its own products payable by Part D presents a heightened risk of fraud and abuse, and that nothing in OIG laws or regulations prevents manufacturers from helping uninsured patients and Medicare beneficiaries who have not enrolled in Part D.

A Part D plan's formulary exception is a separate request that rests on the prescriber's supporting statement, covered in how to fax a formulary exception request.

What delays or sinks an application?

An incomplete or unreadable application delays a patient assistance program decision, and the programs' own pages name these causes:

• A missing second form. The Genentech Patient Foundation takes no action until it has both the Patient Consent Form and the Prescriber Foundation Form.
• Missing information. Sanofi Patient Connection follows up with the healthcare provider when an application is missing information, and the decision takes longer.
• An unreadable fax. NovoCare is moving enrollment to online only because online enrollment eliminates delays caused by incomplete or unreadable fax submissions.
• A lapsed enrollment. AZ&Me does not automatically re-enroll currently enrolled Medicare patients for 2027, so they complete the 2027 re-enrollment process to keep receiving assistance.

How do you send applications from a HIPAA fax account?

A prescriber's office sends a patient assistance program application from a HIPAA fax account by faxing the signed forms and the income proof to the number on the program's form, then keeping the delivery proof until the program decides. Every Fax Pigeon plan includes e-signatures, so a prescriber can sign a faxed form on screen and send it back without printing. A program's decision or request for more information, faxed to the practice's own number, reaches the team's shared inbox and can be assigned to the person handling the application. The first plan, Basic, is $4.99 a month billed annually for 200 pages, and each plan carries a BAA signed at signup and room for unlimited people.

* Official sources (HHS ASPE, Social Security Administration, Medicare.gov, HHS Office of Inspector General, Merck Patient Assistance Program (MerckHelps), AZ&Me, Pfizer RxPathways, NovoCare, Sanofi Patient Connection, Genentech Patient Foundation, Amgen Safety Net Foundation) were read on October 23, 2026. Fax Pigeon prices and plan terms as of October 24, 2026.