Use this page to access all of the texting forms currently available to send directly to our patients Request Proof of Income Request Proof of Income Use this form to text your patient a link requesting their proof of income for a patient assistance program application:Patient Name Full Name LanguageEnglishSpanishPhoneI 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. Δ Patient Assistance Program Companies and Phone Numbers Ask patient to follow up with the PAP company Use this form to text your patient a reminder to call the patient assistance program company and check on the status of their applicationMedicationAdmelogAtrovent HFACombivent RespimatEliquisEntrestoEyleaFarxigaFiaspGlyxambiGSKJardianceLantusLevemirLisproNovolin 70/30Novolin NNovolin ROzempicProair RespiClickQVAR RedihalerRybelsusShingrixSkyriziSpiriva HandiHalerSpiriva RespimatStiolto RespimatStriverdi RespimatSymbicortSynjardiSynjardi XRTradjentaTresibaTrijardy XRTrulicityVictozaCompanySanofiPhoneFax NumberPatient Name Full Name LanguageEnglishSpanishPhoneI 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. Δ Ask Patient to Donate Towards Imaging Imaging Cost Form with Texts Use this form to check the cost of the procedure your patient needs: Type of TestBreastTransvaginalUltrasoundX-RayCTACTPETMRIMRADEXACOLORECTAL CANCER SCREENINGAvailable TestBREAST SCREENING TOMOSYNTHESIS BIBREAST TOMOSYNTHESIS BIBREAST TOMOSYNTHESIS UNIBREAST COMPLETE ULTRASOUNDBREAST LIMITED ULTRASOUNDBREAST SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CADBREAST MRI WITHOUT CONTRAST MATERIAL UNILATERALBREAST MRI WITHOUT CONTRAST MATERIAL BILATERALBREAST MRI W/OUT&WITH CONTRAST W/CAD UNILATERALBREAST MRI WITHOUT&WITH CONTRAST W/CAD BILATERALCost of Test100Would you like to text you patient this information?YesNoText InformationComplete this form to send your patient a text message with the cost of their procedure and the donation page link. Patient Name First Last LanguageEnglishSpanishPhoneI 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. Δ
