IPAP Application

Institutional Patient Assistance Program (IPAP) Application

Contact Information
Main Contact
Title
Phone Number
Email Address	Invalid email address
Who will be responsible for monitoring and tracking the prescription for the Pfizer Institutional Patient Assistance Program?
Name
Title

Facility Information
What type of facility are you representing?
Free Clinic Federally Qualified Health Center Hospital State Program
Does the facility serve patients that are uninsured?	Yes No
Is the facility a non-profit organization organized and operated in accordance with section 501(c)(3) of the Internal Revenue Code of 1986, as amended?	Yes No
Does the Facility have an in-house pharmacy that is owned and operated by the Facility?	Yes No
Is the facility funded under one of the following sections of the Public Health Service Act?	Yes No
30 E: Primary Care Community Health Center (CH) 330 G: Migrant Health Center (MH) 330 H: Homeless Health Center (HCH) FQHC L-A: Certified Federally Qualified Health Center Look Alike (Letter)
Is the facility able to complete a Pfizer Patient Assistance Foundation inspection and have satisfactory results?	Yes No
Can authorized personnel at the facility electronically submit replenishment requests to the Pfizer IPAP secure website system using a XLS or CSV file?	Yes No
Does the facility provide health care items and services free of charge to qualified patients?	Yes No
Does the facility charge a dispensing fee?	Yes No
Does the facility participate in the 340B Drug Pricing Program as a Disproportionate Share Hospital?	Yes No

Program Information
Is the pharmacy licensed?	Yes No
Are there any other dispensing facilities (e.g. dispensing offices)?	Yes No
Number of additional Federally Qualified Health Center sites or programs	Invalid number
Number of patients seen per year	Invalid number
Percent of Medicaid patients in the last full calendar year	Invalid %
Percent of Medicare patients in the last full calendar year	Invalid %
Percent of Low Income/Uninsured Patients in the last full calendar year	Invalid %
Number of bulk replacement patient assistance programs	Invalid number
Names of other bulk replacement patient assistance programs