Applications must be received by the last day of the month to be considered for assistance in the following month. 

Completed forms may be faxed, mailed or emailed to us.  If you need an application mailed to you, please call our patient assistance line.

Patient Assistance Line:       918.286.5699
Fax:                                  918.249.7511
Mailing Address:                 PO Box 700392
                                        Tulsa, OK 74170-0392

Apply for Assistance