The Assistance Fund

First Name *

Please include your first name.

Last Name *

Please include your last name.

Phone Number *

Please include your phone number.

Email Address *

Please include your email address.

Confirm Email Address *

Please make sure your email matches.

Note: When registering for TAF’s Provider Portal, please use your own individual email address associated with your employer. Registrations using private email addresses (e.g., Yahoo, Gmail, Hotmail, etc.) or generic email addresses (e.g., billing@pharmacy.net) will be rejected.

Contact type *

Please select a contact type.

Provider Name *

Please include a pharmacy name.

NPI (National Provider Identifier) *

Please include your NPI.

I accept the Provider Portal Terms of Use.

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