Back to upload secure documents page Secure document upload form Secure Document Upload 1Patient Identification2Document Upload3Terms and Conditions Are you a patient?(Required) Yes No 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:You can upload documents on behalf of the patient. 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 NumberFill 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? Please describe the issue to the best of your ability and upload the appropriate documents.Description(Required)Upload files here(Required) Drop files here or Select files Accepted file types: pdf, png, jpg, jpeg, doc, docx, Max. file size: 10 MB, Max. files: 33. Does this all look correct? Review and consent to our terms and conditions Read carefully before you submit the information 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 submitted information 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 NameThis field is for validation purposes and should be left unchanged.
