We assist you in applying for Patient Assistance Programs provided by pharmaceutical companies, helping you access brand-name medications at no cost.
The Advocacy Service Center, LLC. is a fee-based medication advocacy service that assists patients in enrolling in applicable pharmaceutical companies’ patient assistance programs.
You hereby authorize The Advocacy Service Center, LLC. to act on your behalf and to sign applications for patient assistance programs by hereby granting to The Advocacy Service Center, LLC. a limited power of attorney for the specific purposes of enrolling you in patient assistance programs and any related activities to process your enrollment.
You understand this authorization can be revoked at any time by you by providing a signed letter of cancellation to The Advocacy Service Center, LLC. as described in the Fees section.
You hereby authorize your healthcare provider’s office to discuss/release medical information to The Advocacy Service Center, LLC. relating to your applications for patient assistance programs that The Advocacy Service Center, LLC. is processing on your behalf.
You understand that The Advocacy Service Center, LLC. does not ship, prescribe, purchase, sell, handle, or dispense prescription medication of any kind. The pharmaceutical companies offer the medication through patient assistance programs at no cost. You hereby acknowledge that you are not paying for medication(s) through the The Advocacy Service Center, LLC. service; rather you are paying for the administrative service of ordering, managing, tracking, and refilling medications received through the The Advocacy Service Center, LLC. medication advocacy service.
You also understand and acknowledge that it is each individual pharmaceutical manufacturer who makes the final decision as to whether you qualify for their patient assistance programs.
You understand The Advocacy Service Center, LLC. does not guarantee your approval for patient assistance programs; it is up to each applicable drug manufacturer to make the eligibility determination.
You will be provided details in writing for each of your eligible medications. The medication is shipped directly from the pharmaceutical company and is delivered either to your home or healthcare provider’s office, depending upon the manufacturer delivery guidelines.
You agree that you may be contacted via telephone, cellular phone, text message or email through all numbers and/or addresses provided by you and authorize receipt of pre-recorded and/or artificial voice messages and/or use of an automated dialing service by The Advocacy Service Center, LLC. and/or its affiliates.
By signing below, you further agree to release The Advocacy Service Center, LLC., its agents, employees, successors and assigns from any and all liability including legal fees and costs arising from medication(s) taken by you which were procured through the The Advocacy Service Center, LLC. medication advocacy service and/or your reliance upon the program in general.
You further agree to indemnify and hold The Advocacy Service Center, LLC., its agents, employees, successor and assigns harmless against any and all damages including legal fees and costs arising from third persons ingesting any medication procured for you through The Advocacy Service Center, LLC. Medications covered are subject to change at any time.
The Advocacy Service Center, LLC. reserves the right to rescind, revoke, or amend its services at any time.
If you do not receive medication because you were determined to be ineligible for a patient assistance program, and you have a letter of denial by the applicable pharmaceutical manufacturer, The Advocacy Service Center, LLC. will refund the monthly administrative service fee for the medication determined to be ineligible. All The Advocacy Service Center, LLC. will need from you is a copy of the denial letter sent to you from the applicable drug manufacturer explaining why you are ineligible.
We value our patients and make extreme efforts to protect the privacy of our patients’ personal information. Patient information is processed for order fulfillment only and for no other purpose. Patient information, including all patient health information and personal information, will never be disclosed to any third party under any circumstances. All information given to The Advocacy Service Center, LLC., its agents, employees, successors and assigns (collectively, “The Advocacy Service Center, LLC.”) will be held in the strictest confidence.
The Advocacy Service Center, LLC. charges a service fee of $60 per month for each medication. The monthly service fee covers 100% of the medication cost, as well as the services provided by The Advocacy Service Center, LLC. There are no additional costs for the medication(s). If we find that we are unable to access at least one of your medication(s) during the initial enrollment process, there will be no charges to your account. If we can access your medication, the initial service fee will be debited immediately so we can begin processing the paperwork required to order each eligible medication. The initial processing of your medication order(s) ranges from an average of 4 to 6 weeks and is contingent upon prompt responses to information that we request from you and your healthcare provider(s). The Advocacy Service Center, LLC. will process your monthly service fee on the same day each month corresponding to your enrollment date. This monthly transaction will appear on your statement as “ADVOCACY SERVICE CENTER”. You also agree to pay any associated fees should your EFT (electronic fund transfer) be returned unpaid by your financial institution. Due to the service-based nature of The Advocacy Service Center, LLC., there are no refunds other than what is explained in The Advocacy Service Center, LLC. Guarantee above. Advocacy Service Center reserves the right to change its price at any time, with or without notice.
You are experiencing a hardship with affording your medication and/or you currently do not have coverage that reimburses or pays for your prescription medications. You affirm that the information provided on this form is complete and accurate. If you determine the information was not correct at the time you provided it to The Advocacy Service Center, LLC., or if the information was accurate but is no longer accurate, you will immediately notify The Advocacy Service Center, LLC.
The Advocacy Service Center, LLC.
141 NW 20th Street Suite G6
Boca Raton, FL 33431
