Case Submission Form

Thank you for your interest in Sustain Meds! Prescription medication health care services – Including prior authorizations and copay assistance – are highly customized based on each individuals unique case. Our team looks at each customer on a case by case basis to ensure our services can save you money and obtain the outcome you are trying to achieve. Because of this, we ask every visitor interested in our services to fill out some basic personal information. This information will be reviewed to ensure we can best assist you. We will contact you back via your preferred method to continue the conversation.

First Name

Last Name

Email Address

Telephone Number

Preferred Contact Method Preferred Contact Method Email Telephone

Please select your insurance status Please select your insurance status Commercial Insurance Medicare Insurance Uninsured

How many family members live in your household, including yourself?

What is your total annual household income?

Please list any expensive medications you have been prescribed

How did you hear about Sustain Meds?

Please enter the insurance agent's name

Sustain Meds is a leading Authorized Representative that acts on the patients behalf to ensure their prescription treatment plan issued by the doctor has the best chance of getting through the administrative process.

ADDITIONAL RESOURCES

LET'S GET SOCIAL