PATIENT ASSISTANCE PROGRAM
What is the Patient Assistance Program (PAP)?
The MIMEDX Patient Assistance Program assists uninsured patients who are unable to afford EPIFIX and EPICORD product families.
Criteria
Product that is free of cost is awarded to patients in need who meet all the below criteria:
The Patient is a United States citizen or a lawful permanent resident in the United States and/or Puerto Rico.
The Patient is under the direct care of a licensed HCP, who is practicing medicine in the U.S. or Puerto Rico.
The Patient is prescribed a Company product for the treatment of a Diabetic Foot Ulcer (DFU) or a Venous Leg Ulcer (VLU) for which standard of care treatment has failed.
The patient does not have health insurance (i.e., commercial, governmental, state, local or special services).
The patient has a household income that falls below 250% of the federal poverty guidelines as published annually by HHS at: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines.
How to Apply
Click here to download forms.
Fax the completed form to MIMEDX customer service at 1-770-590-3552.
There are both provider and patient sections requiring attestation that the patient meets the criteria to apply for the program.
All fields must be completed; incomplete forms will be denied.
How Will I Learn If the Patient is Approved?
For each application, MIMEDX will communicate one of 3 outcomes:
Denied
More info needed
Approved
Frequently Asked Questions
No, the PAP is for patients who do not have any insurance. In this instance, the provider may send a predetermination (medical necessity) request to the patient’s payer.
No, outside of general education about the program, MIMEDX Field Personnel cannot assist with the application in any capacity.
No, the PAP is for Diabetic Foot Ulcers or Venous Leg Ulcers only.
No, only the completed PAP form. MIMEDX may follow-up and ask for additional information as necessary.
The patient only has to attest to income levels on the form. However, MIMEDX reserves the right to request the patient’s tax return from the previous calendar year in order to verify income and eligibility for this request.
To securely transmit Protected Health Information (PHI), only use the fax number provided (770-590-3552) to send the completed forms. Do not use unencrypted email to send PHI.
Your MIMEDX Account Executive and Field Reimbursement Manager can provide general information about the program. If you have questions about a specific application or patient, you can call MIMEDX Customer Service at 866-477-4219.