Once A Year Direct Financial Assistance

To apply for direct assistance, please provide:

Patient’s name
Home address
Phone number
Email address
Neurologist name and hospital or clinic name
Photos of epilepsy medication bottle(s). This MUST show all of the following information:
- your name
- the name(s) of prescribed medication(s)
- the date (to confirm you are currently being treated for epilepsy)
Your preference of Zelle payment or paper check mailed to your address
- If Zelle, fill out your name and phone number associated with your Zelle account. If a mistake is made, the money will not be received by you.
- Please select Zelle payment ONLY IF YOU ALREADY HAVE A ZELLE SET UP. We cannot assist you in creating one!
- Alternatively, if you prefer a check, it will take 1 to 3 business weeks to arrive. By selecting mailed check, you confirm that you agree to this timeline.

PLEASE NOTE:

Pictures need YOUR NAME, the MEDICATION NAME, and the DATE prescribed or last filled. You may send multiple pictures as long as you include all info.

If your images of your medication do not have all of the required information, we cannot process your request, and you will need to resubmit your information and will be at the back of the line!

Name of patient with epilepsy

If you are filling this form out for your child or family member with epilepsy, please put THEIR name here.

First Name

Last Name

Name of guardian, if patient is under 18 or not filing out form themselves

If you are filling this form out for your child or family member and you are not the individual with epilepsy, please put YOUR name here.

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Email Address Confirmation

Please type your email again to confirm.

Name of neurologist and hospital

Please select how you would like to receive your financial assistance

Please note, if you prefer mailed check to your address, it may take up to 3 weeks!

Name and phone number associated with your Zelle account

Do you need to share any more information with us?

I confirm that my information is correct:

By checking this box, I confirm that this information is correct to the best of my knowledge.

I confirm that the medication images include the patient's name, the name of the prescription(s), and the date.

By checking this box, I confirm that I have included the information above. I confirm that if it is not included I will need to resubmit a new request, which will delay me receiving direct assistance.

Once A Year Direct Financial Assistance

To apply for direct assistance, please provide:

PLEASE NOTE:

Pictures need YOUR NAME, the MEDICATION NAME, and the DATE prescribed or last filled. You may send multiple pictures as long as you include all info.

If your images of your medication do not have all of the required information, we cannot process your request, and you will need to resubmit your information and will be at the back of the line!

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