![]() If you are returning to the LLS Financial Assistance Copay Portal, please log in, select Co-Pay Assistance Program, and fill out required fields. If you already have an LLS Financial Assistance Copay Portal Account: Upon completing your application, submit for review.Log on to the LLS Financial Assistance Copay Portal using newly created password.Receive confirmation email (typically within 5 minutes of submitting) and click on the link provided to create a password.Complete the registration form in the LLS Financial Assistance Copay Portal and submit.If this is your first time visiting the LLS Financial Assistance Copay Portal, you will need to register before you can start the online application. If you do not have an LLS Financial Assistance Copay Portal Account: On the template, highlight the placeholder text on the fax cover sheet. LLS offers patients, caregivers, pharmacies, and healthcare providers two easy ways to register/apply: Double click on the Faxes button and find the fax template that is suitable to your preferences. In the event that you are unable to get your doctor to sign off on the Diagnosis Verification Form for your application, we will accept a portion of your electronic medical record (EMR) or other documentation that shows the diagnosis/ICD-10 code. *Healthcare Professionals (HCP) applying on behalf of a patient will be asked for their NPI and tax ID. This information will not be shared and is for verification purposes only. The name of treating physician and their phone/fax numbers.The name of your pharmacy and its phone/fax numbers.Insurance card, as well as Medicare/Medicaid.If the patient is a minor, you will need a guardian Social Security number as well.The patient's demographic information (including their Social Security number and date of birth) and their contact information.STEP 1: Gather the following information. If you prefer to apply on your own, please refer to the information below. ![]() You may call (877) 557-2672 to speak with an Intake Specialist who can walk you through the application process. Please visit our website in the future to become aware of new funding. Program continuation is dependent on the availability of funds and the program could be modified or discontinued at any time if funding is limited or no longer available. Open and accepting applications at this timeĪs a non-profit organization, we rely on the generosity of our sponsors. *Philadelphia Chromosome Negative Myeloproliferative Neoplasms only. ![]() Plasma cell leukemia or plasma cell myeloma.Juvenile myelomonocytic leukemia (JMML) (diagnosis formerly known as chronic myelomonocytic leukemia of infancy ).Please refer to our booklet, Non-Hodgkin Lymphoma, for additional subtypes ( click here). ![]()
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