Patient's Home Address:
To qualify for PAN’s travel assistance programs, the patient must be required to travel more than 20 miles (one way) to receive his or her prescribed treatment. Exceptions to distance requirements are made for patients living in large metropolitan cities. See PAN’s Travel FAQs for details.
Your treatment facilities
|Treatment Facility||Address||City||State||ZIP||Distance from home||Action|
Please attach copy(ies) of your appointment schedule.
No matching providers were found, please revise your search and try again. For assistance, please contact the PAN call center at 1-866-316-7263.
Please select the treating/prescribing provider from the list below. If more than one provider is associated with the patient's treatment, select the primary provider.
Please note: PHI will be shared with the prescribing provider selected below.
|First Name||Last Name||NPI||Organization||Address||City||State||ZIP|
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