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 products.
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 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).
Fax the completed form to MIMEDX customer service at 770.590.3552
There are both provider and patient sections requiring attestation that the patient meets the criteria to apply for the program.
All forms 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 three outcomes to the provider:
Frequently Asked Questions
my patient has insurance but it doesn't cover venous leg ulcers. is this a good candidate for the pap?
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.
can my mimedx account executive or field reimbursement manager assist with the paperwork?
No, outside of general education about the program, MIMEDX Field Personnel cannot assist with the application in any capacity.
my patient is having surgery to debride a large burn in the or. I would like to apply epifix afterward. would this meet the criteria?
No, the PAP is for Diabetic Foot Ulcers or Venous Leg Ulcers only.
as a provider, do I need to submit clinical records for review?
No, only the completed PAP form. MIMEDX may follow up and ask for additional information as necessary.
does my patient have to provide proof of income?
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.
how should providers submit the form? can it be emailed?
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.
as a provider, I have questions about the process. what are my resources?
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.