Enrollment

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Enrollment

QUICK ENROLLMENT STEP 1 OF 6 PERSONAL INFORMATION

Please have the following information available before completing the enrollment form. This Information is required by the pharmaceutical manufacturers in order to fulfill your medication orders.

Your personal information.
Your doctors’ information; including each doctor’s full name, address, phone number, and fax number.
Your medication information; including the name, strength, and frequency of each medication.
Your monthly income.

Please have your payment information ready in order to complete the enrollment process. We accept Visa, Mastercard, or a Checking Account. There are no enrollment fees, application fees or hidden costs. Don't worry, if we are unable to approve you, there will be no charges.

All personal information, including all health information, will never be disclosed to any third parties for any reason and is for order fulfillment purposes only.

First Name * Middle Initial Last Name *

Address * City * State *
ZIP Code *

Phone * Email Address

Protecting your personal information is our #1 priority. We have government-grade, secured software in place to ensure your personal information is always safe.

Questions?

If you have any questions about USA Advocacy's brand-name medication service, call our patient advocates at 855-649-7615.