RESET/O Rebate Form

RESET & RESET-O Financial Hardship Form

Instructions: Please complete this form to apply for a financial hardship rebate on the cost of your RESET or RESET-O digital prescription therapy.

This rebate is offered to help reduce the out-of-pocket cost of your prescription as part of PursueCare’s early experience program. This program will ensure access to treatment while we gather insights to improve patient care. By completing the below, you may be eligible for cost reduction at the discretion of PursueCare.

Patient Name:(Required)

Patient Email:(Required)

Patient Date of Birth(Required)

Annual Household Income:(Required)

Less than $20,000

$20,000 – $40,000

$40,000 – $60,000

More than $60,000

Number of People in Household:(Required)

Please enter a number greater than or equal to 1.

Are you currently receiving any of the following? (Check all that apply):(Required)

Medicaid

Supplemental Nutrition Assistance Program (SNAP)

Supplemental Security Income (SSI)

Unemployment Benefits

Other

None

If other, please explain:(Required)

By signing below, I acknowledge that the information provided above is true and accurate. I understand that the information I have provided will remain confidential and will only be used to determine eligibility for the rebate program. Furthermore, I understand that I will be notified whether or not I am qualified and approved for a one-time rebate, and to what extent the cost may be offset.

Patient Signature:(Required)

Today's Date(Required)

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For Internal Use Only

Product: RESET________ RESET-O________

Subscription Cost: $90.00

Rebate Amount: ________________________

Final Subscription Cost: _________________

Reviewed by: ____________________________