Application Form

Our application form is currently being re-designed. Please use the contact form to start your applicaton process.

While we re-design our web application form, please use the contact form below to send us your information.
This is the first step to receiving your medicine for free, or at the lowest cost possible.

Be sure to include which medicines you currently take so we can begin researching available ways to help you save money.


Your information is safe with us.
We employ industry leading privacy practices.

© 2015-2016 American Prescription Assistance Company. All rights reserved.