Request for Grant Assistance to Cover Contraception Consultation Fees
For Uncompensated Care
Purpose
Increasing access to oral contraceptives is an important service that allows women more control and choice in their life. There is a great need in this state and we are proud of pharmacists that have stepped up to offer this care. To get this program off to a good start when payers often lag behind in adopting payment mechanisms, the APA has solicited grant funding from a generous and anonymous donor to cover uncompensated care. Pharmacies will be provided a $75 to reimburse you for your time and expertise for a full clinical evaluation, consultation, and documentation (typically lasting approximately 30 min).
Name
First Name
Last Name
Pharmacy Name
Currently paying pharmacies directly. We could pay pharmacists individually, but this would require a 1099 for tax purposes.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Email
example@example.com
Number of Uncompensated Consultations
Encounters requiring a full clinical evaluation, consultation and documentation (usually 30 min or greater)
Rx numbers for pharmacist generated prescriptions
Only required in case of an unlikely audit
Additional comments:
Questions, suggestions, feedback, etc.
Submit
Should be Empty: