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BREATHE PENNSYLVANIA PATIENT ASSISTANCE
Medication Patient Assistance Application
Breathe PA is revamping it's medication assistance program to provide medication to individuals with a respiratory diagnosis who are experiencing financial hardship, and is open to residents in the following counties:
This application is designed to be completed by the individual requesting assistance for themselves or their family member. If approved, Breathe PA will work with our partner pharmacy to provide two months of respiratory medication, totaling up to $300/month, to the patient. Medication is mailed directly to the patient's home. This application is a screening tool that allows Breathe PA to collect information to determine patient qualification for the program. If approved, addition information is required, which at a minimum includes:
1. Confirmation of respiratory diagnosis by your doctor's office
2. Respiratory medication prescriptions from doctor's office
3. Copy of the front and back of patient's insurance card
Our office will be in contact to let you know if you qualify to participate in the program. Please allow 5 business days for someone to contact you. Do not send any additional information until you have been approved for the program. This program is subject to change at any time. If you have any questions please call (724) 772-1750 or email info@breathepa.org.