resource(4) of type (mssql link)
* First Name:
  Middle Name:
* Last Name:
* Address:
* City:
* State:
* Zip Code:
* Phone Number: ( -
  Alternate Number: ( -
  Fax Number: ( -
* Social Security Number:
  Alien Number:  
(Only required if no Social Security Number)
* Date of Birth:  
* Email Address:
* Confirm Email Address:

Your (the patient’s) contact information may be used in the future to share printed and/or electronic communications from Patient Advocate Foundation (PAF) and the PAF Co-Pay Relief Program (CPR). If you (the patient) do not wish to receive information from PAF and CPR please uncheck to opt out.

***NOTE: You are not required to participate in the general distribution list in order to use email to correspond about your application.