Good News! We Can Temporarily Assist the Patient Using Our Grant at Galveston Specialty Pharmacy (GSP).

Name

Patient’s Name

MRN

Language

Your UTMB Username

Patient Phone Number

Use this assistant to calculate the approximate cost of the medications at GSP.

Total Cost of RX

Please type in here the total cost of the prescriptions at GSP, use the AI chat above it to quickly calculate it. If unknown, type in 0.

How many refills sent under grant?

Please send prescriptions for 3 months at a time as appropriate with enough refills until the next appropriate follow up.

You patient will receive a text message with a link to sign up for the Kroger membership, incluiding their email address and password. Do you need to add any additional text to their text message?

This is optional, you can leave empty.

I hereby consent to receive SMS messages for the purpose of receiving updates about my patient assistance application. I understand that these messages may include information about the status of my application, medication refill reminders, and other relevant updates. I acknowledge that standard message and data rates may apply, and I am responsible for any associated costs. I may opt-out of receiving SMS messages at any time by following the provided instructions. By providing my consent, I confirm that I have read and understood the terms and conditions of receiving SMS updates. My consent is voluntary and can be revoked at any time.

Good News! We Can Temporarily Assist the Patient Using Our Grant at Galveston Specialty Pharmacy (GSP).

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