To be eligible for MAP's services, the patient must:
1. Be a solid-organ transplant patient
2. Reside in the State of Georgia
Please complete
the following forms to apply for MAP:
1. Patient
Consent Form
2. Patient/Physician Information Sheets
3. Authorization for Use & Disclosure Health Information Form
4. Acceptable proof of income documents.
Please attach copies of current household income and patient's insurance card(s)(both sides).
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 and current household income documentation to MAP:
Medication Access Program (MAP)
UGA Clinical Pharmacy Program
Medical College of Georgia - HM-1200
Augusta, GA 30912
Phone number: (706) 721-0131
Fax number: (706) 721-0754
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
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