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Patient Assistance Information

 
 
 
KOS Patient Assistance Program

KOS Patient Assistance Program
2200 N Commerce Parkway
Weston, FL 33326
Phone : (866) 363-1024 Ext 2
Fax: (954) 331-3778
Eligibility
> The patient must not have any private nor public insurance and have an income at or below 200% of the Federal Poverty Level.
Who Can Apply
> A doctor or nurse must call for an application. The application will be faxed out. The completed application can be faxed or mailed back. The doctor is notified of acceptance or denial. The medication is shipped within 4-6 weeks of recieving the application.
Required
> The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to a 90-day supply is sent to the doctor's office
Ship To
> Physician's office
Note
> A new prescription is needed for each refill. Every year a new application is needed.
 
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader