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.