Common Patient Assistance Program Application form (PDF - 1.2 MB) updated 11/27/2013
HIV Patient Assistance Program Information from the National Alliance of State and Territorial AIDs Directors
HHS, working collaboratively with seven pharmaceutical companies, the National Alliance of State and Territorial AIDS Directors, and community stakeholders, has taken the lead in developing a common patient assistance program application tool for patients and providers. This form is a one-stop shop that collects the necessary information required of HIV patient assistance program applicants.
Prior to the development of the common form, patients and their advocates had to fill out different sets of paperwork to apply for assistance from each company – common for complicated, multi-drug regimens. This was a time-consuming and burdensome process. and the new streamlined application has the potential to provide faster, easier access to live-saving medications.
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