August 14, 2021

Reinaldo Rodriguez
F6 Calle I Bairoa Golden Gate 2
Caguas, PR 00727

Dear Reinaldo Rodriguez:

You recently applied to the Patient Advocate Foundation Co-Pay Relief Program. As you may know,
eligibility for assistance from the Co-Pay Relief (CPR) program is based on the verification of a qualified
diagnosis and demonstrated financial need. The automated income verification system was unable to
verify the household income reported on your application. In light of this, we are requesting that you
submit proof of income and proof of Social Security Number documentation as quickly as possible, but no
later than 30 days from the date of this letter.

Your application status is now pending. It is important that you provide the required income documentation
so that your application may be reviewed for eligibility . If we do not receive the required documentation we
will not be able to process your application.

Required Documentation

Please submit the following documents no later than 30 days from the date of this letter:

Copy of signed federal tax return from most recent tax year (pages 1 & 2 only)
Social Security Number (SSN) documentation

If you are unable to provide a federal tax return from the most recent tax year, you may submit any of the
following documents to verify your household income. Please submit all that apply.

3 consecutive months of complete bank statements -OR- 3 consecutive months of pay stubs -OR-
Salary history and/or salary verification letter from employer
Statement of Social Security benefits (INCLUDING: copy of award letter, check, or recent bank
statement indicating monthly benefit amount
Statement of pension or retirement benefits
Statement of short-term (STD) and/or long-term disability (LTD) benefits received
Statement of Unemployment benefits received
Statement of Alimony and/or Child Support received
Statement of Workers Compensation received
Statement of Dividends and/or Interest income

You may submit your income documentation using any of the following methods:

For applications submitted through our website, the documents may be uploaded to your account
online
For applications submitted by phone, the documents may be faxed using the enclosed bar-coded fax
coversheet, to 757-952-0119
Mailed to : 421 Butler Farm Road, Hampton, Virginia 23666

Toll Free: 1-866-512-3861 | Fax: 757-952-0119 | Tel: 757-952-0118 | cpr@patientadvocate.org | www.copays.org

421 Butler Farm Road | Hampton, VA 23666
We appreciate your timely response to this request for income documentation and we look forward to
continuing our service to you throughout the coming year. If you have any questions regarding this
request, please contact a CPR program specialist at 866-512-3861.

Sincerely,

PAF Co-Pay Relief Program .

Toll Free: 1-866-512-3861 | Fax: 757-952-0119 | Tel: 757-952-0118 | cpr@patientadvocate.org | www.copays.org

421 Butler Farm Road | Hampton, VA 23666
APPCPR202153773-404950-211-1 APPCPR202153773-404950-211-1

PATIENT ADVOCATE FOUNDATION

Co-Pay Relief Program

421 Butler Farm Road

Hampton, VA 23666
Toll Free: 1-866-512-3861 FAX: 757-952-0119

www.copays.org

ATTN: COPAY RELIEF PROGRAM From:

COMPANY: PAF DATE: August 14, 2021

FAX NUMBER: TOTAL PAGES WITH COVER:

PHONE: SENDER’S PHONE:

PATIENT NAME: Reinaldo Rodriguez SENDER’S FAX:

PATIENT CONTACT ID: 404950

SPECIAL INSTRUCTIONS
When faxing application documents, please use this fax cover sheet.
(ex: income documents, physicians form, etc.)

The information contained in this transmittal is privileged and confidential, and intended only for the use of the
individual(s) and/or entity(ies) names above. If you are not the intended recipient, you are hereby notified that any
unauthorized disclosure, copying, distribution or taking of any action on the contents of the telecopied materials is
strictly prohibited. If you have received this transmission in error, please immediately notify us by telephone. Thank you
APPCPR202153773-404950-211-1 APPCPR202153773-404950-211-1