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Request for Reimbursement

Proof of Expenditure Form Instructions

Reimbursement is available for medications covered by the Patient Access Network that are related to the disease state that the patient is receiving assistance for and is subject to an annual benefit limit as determined by the Foundation. The grant awarded will provide assistance for the patient’s responsibility (deductible, co-payment or coinsurance) for covered medication services after the primary insurance has paid. Covered expenses must be for dates of service within the approved eligibility period. All eligible expenses must be submitted within 120 days of the patient’s eligibility end date.

A completed and signed Proof of Expenditure form is required in order to receive reimbursement!
Please see the instructions below to expedite your payment:

1. Please insure that the following information is provided on the Proof of Expenditure form:.

Place a check-mark in the correct box for the type of service provided for Expense One and/or Expense Two :

  • Physician Office Services
  • Pharmacy
  • Outpatient Hospital Services
  • Other (if Other is selected please describe the type of service in the space provided)

2. Please provide the information requested:

  • The date (month/day/year) the medication was received
  • Amount of reimbursement being requested for the medication.
  • The name of the party that the check should be made payable to
  • The complete address to which the check should be mailed to
  • Payments may be issued to the patient or the health care provider

3. Required Documentation To Submit With The Completed Proof of Expenditure Form:

  • Itemized invoice or itemized statement from the provider of service (physician, pharmacy or hospital)
  • Pharmacy prescription labels
  • Proof of payment by the primary insurance (ex. Explanation of Benefit from the primary insurance. In lieu of the Explanation of Benefit the itemized invoice or itemized statement is acceptable if it includes the primary insurance payment)
  • Receipts as proof that you have paid for the services for which you are requesting reimbursement
  • Payment cannot be issued without the required documentation indicated above

4. Proof of Expenditure forms may be submitted as needed and will be reviewed and processed upon receipt. Payment will be issued on a monthly basis or when eligible expenses total $100 or more, whichever comes first. Total payment request amounts of less than $5 will not be reimbursed.

5. The Proof of Expenditure form must be signed and dated by the person approved for financial assistance through the Patient Access Network. The completed form should faxed or mailed with all required documentation to:

Patient Access Network Foundation
PO Box 221858
Charlotte, NC 28222-1858
Fax: 1-866-316-7261 (toll free)

  • You will receive a detailed statement each time a payment is issued to you or on your behalf
  • For questions about the Proof of Expenditure Form or the billing process, please call the Patient Access Network Billing Team at 1-866-316-7263, ext. 72224.

Click here to download form.