The following Proof of Expenditure Forms must be used to access financial assistance through the Patient Access Network Foundation. Assistance is available for products and services that may be subject to an annual benefit limit as determined by the Foundation.
This assistance may be used to address your deductible, copayment and coinsurance obligations. Please consider the following when completing and submitting Proof of Expenditure Forms to the Patient Access Network Foundation.
1. For each expense, please complete the following information for each expense for which you are seeking reimbursement:
- Type of product or service provided. Please select from the list provided (Physician Office Services, Pharmacy, Outpatient Hospital Services, or Other). If other, please describe in the space provided.
- Date product was received or that service was provided.
- Amount of reimbursement being requested for this product or service.
- To whom the check should be made payable.
- Address to which the check should be mailed.
2. The Proof of Expenditure form must be signed and dated by the person completing the form. Once complete, please fax or mail the form and all required documentation to:
Patient Access Network Foundation PO Box 221858 Charlotte, NC 28222-1858 Fax: 1-866-316-7261 (toll free)
3. Invoices, receipts, statements or other expense documentation must be included for each product or service for which you are requesting reimbursement. Payment cannot be issued without adequate expense documentation.
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.
5. Payments may be issued to the patient or the health care provider. For each submitted expense, please indicate to whom payment should be issued. You will receive a detailed statement each time payment is issued to you or on your behalf.
6. Expenses incurred more than 90 days prior to your approval for the Foundation are not eligible for payment, and expenses incurred after your Foundation term of eligibility has ended or after your annual benefit limit has been met are not eligible for payment.