Join the PAN family album: 20th anniversary edition

We’re celebrating 20 years of changing lives with a digital photo album of PAN grant recipients, partners, and supporters. Use our simple sharing tool to send your selfie and tell us why PAN matters to you!

Send your selfie

Verify your income form

1Patient Identification

2Income Verification

3Terms and Conditions

Are you a patient?(Required)

Yes

What is your relationship to the patient?(Required)

I’m a family member or caregiver

I work in a healthcare provider’s office

I work in a pharmacy

Other

Please fill out the following information so we can verify your identity:

Thank you. We’d like to gather your contact information in case we need to reach out with any questions.

First Name(Required)

Last Name(Required)

Email Address(Required)

Phone Number

Date of Birth(Required)

MM slash DD slash YYYY

Patient PAN Member ID (optional)

Fill out the following information so we can verify your patient’s identity:

Patient's First Name(Required)

Patient's Last Name(Required)

Patient's Email Address (optional)

Patient's Phone Number(Required)

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Patient PAN Member ID (optional)

Does this all look correct?

It’s time to verify your income.

Do you have your most recent 1040 tax form?(Required)

Yes

Upload your most recent 1040 tax form here. PDFs are prefered(Required)

Drop files here or

Accepted file types: pdf, png, jpg, jpeg, gif, doc, docx, Max. file size: 10 MB, Max. files: 33.

We need some more information to verify your income. Fill out the following information:

Your PAN Member ID(Required)

Household size(Required)

Annual income(Required)

Reason for not having 1040 tax form(Required)

Confirm(Required)

I confirm the information provided above is accurate and correct.(Required)

It’s time to verify your patient’s income.

Do you have their most recent 1040 tax form?

Yes

Upload the patient's most recent 1040 tax form here. PDFs are preferred.(Required)

Drop files here or

Accepted file types: pdf, png, jpg, jpeg, gif, doc, docx, Max. file size: 10 MB, Max. files: 33.

We need some more information to verify the patient’s income. Fill out the following information on the patient’s behalf:

Patient PAN Member ID(Required)

Patient household size(Required)

Patient annual income(Required)

Reason for not having 1040 tax form(Required)

Confirm(Required)

I confirm the information provided is accurate and correct.

Review and consent to our terms and conditions

Read this carefully before you submit your reported income through the form. By submitting information to the PAN Foundation and clicking “I agree”, you’re confirming that you have read, understand and agree to the PAN Foundation’s terms and conditions as follows:

You attest and certify under penalty of law that the reported income is complete and accurate.
You acknowledge and understand that any false or incomplete information that you provide in your application or through this form could harm the PAN Foundation, including its reputation and tax-exemption status. It could also constitute fraud for which you may be legally liable.
You acknowledge and understand that if the PAN Foundation provides you with assistance and then becomes aware of any inaccurate information or fraudulent activity related to your application or the provided assistance, PAN will terminate your grant and may recoup the provided amount.

(Required)

I agree

Phone

This field is for validation purposes and should be left unchanged.

Apply

Get to know our grants and application process.
Learn more
Advocate

Get to know the ways PAN is advocating for healthcare access.
Our work
Donate

Help us support the millions who struggle to afford medications.
Donate