To order PAPrx software, fax this
completed form to
Date:
|
PAPrx Order Form
|
Shipping Information* Billing
Information (if different)
Company: * Company:
*
____________________________________ _________________________________
Contact Name/Title: * ____________________ Contact Name/Title: *____________________
Address 1: * ___________________________ Address 1: _____________________________
Address 2: ___________________________ Address 2: _____________________________
City State Zip: * ________________________ City State Zip: __________________________
Phone: * _____________________________ Phone: _______________________________
Fax: * _______________________________ Fax: * ________________________________
Email:
______________________________ Email: ________________________________
*
- required
Number of Rx’s Ordered:
*Circle one 200\$200
400\$400 1000\$1000 Order
$20.00
Add $20 Shipping and Set-up fee for initial purchase.
Shipping\Set-up:
If
If Tax-exempt, please include exemption form.
No Sales Tax Necessary Outside
Hours per week
currently spent filling out PAP forms: ___________________
Number of
patients per month that qualify for PAP programs: ____________________
Patient Assistance Program Rx
PO Box 161711
Austin, TX 78716
My organization's
primary target area is:
·
Urban
·
Suburban
·
Rural
·
Statewide
My
organization is affiliated with:
·
Migrant Clinicians Network (
·
Clinical Directors Network (
In order
to use PAPrz software effectively, it is necessary to
download updates from the Internet. Can you download updates from the
Internet?
My organization can BEST be described as:
·
Free clinic
·
Physician's office
·
Government agency, such as a health department
·
Referral network or "clinic without walls"
·
Federally qualified health center
·
Hospital
·
Pharmacy
·
Homeless shelter or agency
·
Free clinic association
·
Medical or dental association
·
Consultant
·
Primary care association
·
Other non-profit