Application

To be eligible for MAP's services, the patient must:

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

Please complete the following forms to apply for MAP:

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
1120 15th Street, AD-3430
Augusta, GA 30912-2450

Phone number: (706) 721-0131
Fax number: (706) 721-0754
E-Fax number: (706) 446-2810

Tips for Effective Correspondence to MAP

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