MedData Services

Additional Information

If you are a Healthcare provider and would like a MedData Services Representative to call and provide you with more information on how our program works and the benefits it can provide to your Healthcare facility and your patients please complete and submit this form. If you do not wish for a Representative to call, please do not complete and send this form. We regret that we are not able to work with individual patients at this time. If you are an individual and feel that you might qualify for these programs we recommend that you ask your physician to contact the manufacturer of your medication to see if you might qualify for their program. Thank you for your interest in MedData Services Prescription Assistance Program.

First Name:		Last Name:
Company:		Your Email:
Address:
City:	State:	Postal Code:
Phone: ( ) -
Are you currently providing prescription assistance to your patients? Yes No
If yes: How many patients are you assisting?
Are you currently using a Manual or Automated System?
Will you be using the System for Inpatient Outpatient or Both?
Are you a 340B Prime Vendor Participant? Yes No
Have you viewed the MDS Demo? Yes No Click here for Flash Demo
Type Of Facility:
How did you hear about us?
Please do not 'Submit' if you do not want to be contacted.