Medication & Prostheses Application

Choose how you would like to apply:

Complete the application below, following the instructions within the application, OR
Complete paper forms, Medication & Protheses Assistance Application and Confirmation of Diagnosis, and mail them to The APG Foundation, P.O. Box 1248, Cedar Rapids, IA 52406-1248 OR scan and email the documents to info@apgfoundation.org.

Applicant

Name: (required)

Street Address: (required)

City: (required)

State: (required)

ZIP: (required)

Telephone: (required)

Email address: (required)

Patient Birth Date (yyyy-mm-dd): (required)

Physician Information:

Physician Name:

Office address:

How did you learn about APG Foundation?

Required Supporting Documents

Please provide documents outlined below.

You may submit digital copies (PDFs or images) with this form, or you may send print copies to APG Foundation, P.O. Box 1248, Cedar Rapids, IA, 52406-1248

By submitting your information electronically, you acknowledge that you submitted protected health information (PHI). Please be aware that email communication can be intercepted in transmission or misdirected.

Receipt(s) that include the date, applicant’s name, name of medication or prosthesis and the amount paid.
Completed confirmation of diagnosis form (PDFs or images)

Consent & Authorization

By submitting this form:

I attest that to the best of my knowledge the information provided is accurate.
I affirm that I have no other readily available means to purchase prescribed medications and prostheses.
I agree to provide a confirmation of diagnosis form and receipt(s) with information identified above.
I agree to provide further information if needed.

I Agree