Once A Year Direct Financial Assistance

 

To apply for direct assistance, please provide:

  • Patient’s name

  • Home address

  • Phone number

  • Email address

  • Neurologist name and hospital or clinic name

  • Photo(s) of epilepsy medication bottle(s) showing all of the following information:

    • your name

    • the name(s) of prescribed medication(s)

    • the date (to confirm you are currently being treated for epilepsy)

  • Your preference of Zelle payment or paper check mailed to your address

    • If Zelle, fill out your name and phone number associated with your Zelle account

    • Alternatively, if you prefer a check, it will take 1 to 3 business weeks to arrive. By selecting mailed check, you confirm that you agree to this timeline.

PLEASE NOTE: If your images of your medication do not have all of the required information, we cannot process your request, and you will need to resubmit your information and will be at the back of the line!