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Questionnaire/Application

Dear Friends,

It is our hope that the Demetricia C. Patterson Foundation has or will be able to assist you in some small way with the difficulties that you have encountered in trying to make ends meet on a daily basis. In order to help as many people as we can, it is important that you read the following disclosures.

Thank You.

 

1)  All approved payments will be made to the drug suppliers (vendors) only.

2)  Payments will only be made when funds are available.

3)  There will be only one (1) assistance payment per client per year.

4)  Services can only be provided per all guidelines and rules as set forth by the DCP Foundation. There can be no exceptions to these guidelines and the client must have proof of a life-threatening condition such as Heart Problems, Cancer, Diabetes, High Blood Pressure and/or HIV/AIDS.

5)  The DCP Foundation will pay up to 50% on one (1) or two (2) medications only.  No exceptions.  For example, the Foundation will provide assistance for up to 15 pills of a 30 pill prescription or up to 2 weeks of a one month supply of a prescribed medication.  The percentage depends on the funding availability at the time of an applicant's approved application for assistance.

6)  The DCP Foundation will provide an applicant with a decision of approval or denial within 7-10 days of receipt of the application.

7)  All applications must be completed and all requested information must be true and certifiable before a decision may be given.  The applicant may return the application online or by e-mail, fax or mail within 30 days.

8)  The DCP Foundation will process an application in as timely a manner as possible.  The applicant is responsible for applying for assistance in as timely a manner as possible and the Foundation will assume no responsibility for an applicant whose prescription has run out.

9)  The DCP Foundation cannot be held responsible for payment to any vendor prior to an applicant's normal approval or denial timeframe as noted above regardless of when the prescription order is due.

10)  The DCP Foundation is prohibited in the delivery of any medication to an approved application.

11)  It is the sole responsibility of the applicant and/or their caregiver to seek out and obtain all requested information from their medical provider as well as all other information that is requested on the application.

12)  It is the sole responsibility of the applicant and/or their caregiver to call in their order for their medication(s) to their vendor.  The DCP Foundation will on pay  assistance that has been awarded to the vendor by mail.

13)  The DCP Foundation is a pay assistance program for seniors only.  A senior is described as an applicant aged 50 or older. . No exceptions.

14)  The DCP Foundation provides no other services other than those that have been described above.  The DCP Foundation is bound by all rules and regulations of the Foundation.

  Abbott Laboratories   Pfizer   AARP   Johnson & Johnson   WellPoint   Air Tran   AT&T

  Lilly   Pay Pal   Microsoft   Edward Jones   Walgreens   Wachovia   Carnival   Apple Inc.

PO Box 1323   New Smyrna Beach, FL  32170

386-689-9694   386-427-2112   Fax: 386-427-2272

dcpattfndt1@bellsouth.net    dcpfndt@DCPatterson.com

Demetricia C. Patterson Foundation

Non-Profit Assistance Drug Program for Senior Citizens