ASAP Enrollment form checklist

6900 College Blvd. Ste 1000 • Overland Park, KS 66211
Phone: 1-877-ASAP102 (1-877-272-7102) • Fax: 1-877-801-0777

Please ensure that the application is fully completed and that all supporting documentation is included. Incomplete or missing documentation may result in delays in processing the application.

Please include the following documentation when submitting this application for consideration into the ASAP program:

  • Medicaid Eligibility Denial Letter, or date on which patient applied for Medicaid
  • Copies of insurance cards, front and back (if patient is insured)
  • Copy of unfavorable decision letter from final level of appeal (if patient is insured)
  • Proof of Gross Annual Household Income in one of the forms listed below:
    • Previous year’s W-2 or tax return
    • 3 months of checking account statements showing amount
      of income deposited and the company depositing the income
    • A full month’s worth of pay stubs
    • Social Security benefit award letter or check
    • If patient has no income
      • A notarized letter from the family stating that patient has zero income with an explanation of how patient is supported
      • A signed zero income letter from the physician, including an explanation of how patient is supported, on the physician’s letterhead

You can download the ASAP Enrollment Form here.

You may fax the application to 1-877-801-0777 or mail it to:

Allos Support for Assisting Patients
c/o AccessMED, Inc.
6900 College Blvd. Ste 1000
Overland Park, KS 66211

Please call 1-877-ASAP102 (1-877-272-7102) if you have any questions regarding the application or the ASAP program.

Thank you,

ASAP Reimbursement Counselor