Prequalification Form

Patient eligibility is based on several factors. Each pharmaceutical company program has it's own requirements. WebPAP maintains those requirements on a daily basis. Then WebPAP compares the patient information to the requirements for a quick review.

Eligibility is auto calculated for you. Click here to see a Qualify image, Click here to see a Not Qualified image.

What is your monthly household income?  
How many people are in your household?  
Are you currently receiving any of the following?


Medicaid



What is your current residency status?





   
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