PAP Foundation J.A. Assistance Fund Application

Jonathan Alkalai PAP Foundation Patient Assistance Fund Application
Before applying, please review details of the fund, as well as the eligibility criteria and covered expenses, at https://www.papfoundation.org/ja-assistance-fund.
Applicant Information
Full Name*

First NameLast Name
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Insurance and PAP Diagnosis
Are you a United States citizen or a U.S. resident of six months or greater?*

YesNo
Are you enrolled in either Medicaid, Medi-Cal, or Medicare insurance programs?*

YesNo
Please upload a copy of your insurance card here:*

Cancelof
Do you have a prior diagnosis of Autoimmune Pulmonary Alveolar Proteinosis (aPAP)?*

YesNo
What was your method of diagnosis?*

BronchoscopyLung BiopsyAnti-GM-CSF Autoantibody Blood TestOther
If other, please describe below:
What is the name of the physician that provided the above diagnosis?*
What institution or hospital system is or was the above physician affiliated with?
Do you allow the PAP Foundation to reach out to the physician above to confirm the diagnosis of aPAP?*

YesNo
Assistance Programs
The J.A. PAP Foundation Patient Assistance Fund currently consists of two assistance programs.
1. The Copay Assistance Program assists eligible PAP patients who have health insurance with funding to cover health insurance deductibles, copayments, and coinsurance costs associated with care of PAP. Examples of expenses include:
  - medical expenses paid towards an insurance deductible
  - copayment for office visits
  - out-of-pocket expenses for an ER visit
  - a coinsurance payment for consult with a PAP specialist
2. The Travel Assistance Program assists patients with expenses for travel to and from a PAP-related medical appointment. Examples include gas mileage, lodging, economy airfare, and food.
Which Assistance Program will you be applying for? (select one or multiple)*

Copay Assistance ProgramTravel Assistance Program
Are there additional comments / questions you would like us to consider?
If you have additional questions or comments, let us know here.
What next?

Following application submission, applications will be reviewed by the PAP Foundation. If accepted, PAP patients will have the opportunity to submit a limited number of covered expenses for reimbursement.

For any questions please reach out to jonathana@papfoundation.org or brennac@papfoundation.org at the PAP Foundation.
Should be Empty:

Jonathan Alkalai PAP Foundation Patient Assistance Fund Application

Applicant Information

Health Insurance and PAP Diagnosis

Assistance Programs