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Patient Enrollment

1. Apply with the help of a registered prescriber. The patient application can be filled out on-line and then printed.
2. Gather income documentation.
3. Prescriber faxes the application. The completed and signed application, with supporting income documentation, should be faxed to 1-877-VAC-1555.
4. Wait 10 minutes for a reply. The application will be processed and notification of acceptance or denial will be faxed back within 10 minutes.
5. Prescriber administers the vaccine, once notification of acceptance into the program is received.
6. Subsequent doses require that the Dose Authorization Request Form has been received and approved by the program.
7. Patients can re-apply. Enrolled patients are eligible to receive additional doses of vaccine that are available through the program for up to one year. If needed, the patient can re-apply for continued assistance.