Forms

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We've made all the necessary forms available for download on our website. We encourage you to review the forms carefully and fill them out completely to ensure a smooth and hassle-free application process. If you have any questions or need assistance with the forms, don't hesitate to contact us – we're here to help!

Initial application

Patient application packet

Supplemental

Other

We're here to help you every step of the way!

Reach out to us
Please call (408) 970-2001.
We are open Monday - Friday,
9:00am - 5:00pm.

Start your application

Are you ready to start your application? Visit our portal page to begin your application today! It includes some easy to follow questions and the opportunity to submit your documents.

Start your MedAssist application

How to apply

Apply now and start enjoying the benefits of our money back program!

Apply for MedAssist

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FAQs

Got questions about MedAssist?
Check out our FAQs for answers to some of the most commonly asked questions.

Get answers

Learn more about MedAssist

Ready to learn more about how our money back program can benefit you? Dive deeper into the program by exploring our website and discovering all the ways we can help you earn cash back. Don't miss out on this opportunity to save money and protect your health.