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H H S Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Programs

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Common Patient Assistance Program Application

Common Patient Assistance Program Application form (PDF - 1.2 MB) updated 11/27/2013

HIV Patient Assistance Program Information go to exit disclaimer 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.

Learn more: Common application for HIV patient assistance program expedites application process for lifesaving drugs (09/12/2012)

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