pharmacist on computer looking up information and holding a perscription

Application

STEP 1: Be eligible for MAP’s services

The patient must:

  1. Be a solid-organ transplant patient
  2. Reside in the State of Georgia

STEP 2: Complete Forms

Patient / Physician Information Sheets
HIPAA Authorization Form
Patient Consent Form 17

You must also read the HIPAA Policy page for a full understanding.

If you would like for MAP to help you enroll a patient into a medication assistance program, please complete, print, and mail or fax the HIPAA Authorization form, information data sheet, and the patient consent form to:

Medication Access Program (MAP)
UGA Clinical Pharmacy Program
Augusta University Medical Center
Solid Organ Transplant Center
Wellcare MCG Medical Center
1120 15th Street, AD-3430
Augusta, GA 30912-2450

Phone number: (762) 375-1244
Fax number: (706) 721-0754
E-Fax number: (706) 446-2810

STEP 3: Prepare Your Information

Please have the following information available when you contact MAP:

  • Patient’s name
  • Patient’s address
  • Patient’s telephone number
  • Patient’s social security number
  • Patient’s date of birth
  • Patient’s date of transplant
  • Patient’s household income amount
  • Medications that the patient is taking
  • Patient’s medication dosage
  • Physician’s name
  • Physician’s address
  • Physician’s telephone number
  • Transplant center following patient