Lyme tap form 2012-2026

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The Lyme Test Access Program (Lyme-TAP) is a nationwide initiative by the Ferndale Foundation and Lyme Patients Assistance Group that provides financial assistance for initial Lyme-related lab tests to patients in genuine financial need. Eligible applicants can receive reimbursement of up to 75% of their out-of-pocket testing costs from approved laboratories. The program prioritizes children under 18 and requires proof of financial hardship, including tax returns and lab receipts. It aims to support patients without insurance coverage for necessary tests.

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Click ‘Get Form’ to open the Lyme TAP form 2012 in the editor.
Begin by filling out your personal information, including your name, address, and contact details. Ensure all entries are clear and legible.
Provide your healthcare provider's information. This includes their name, address, and phone number. This section is crucial for verifying medical necessity.
In the Diagnostic Test Information section, list the tests performed along with their costs. Indicate if you have been tested previously.
Complete the Statement of Financial Need by selecting the basis for your application (low income or other circumstances) and attach necessary documentation such as your 1040 Federal tax return.
Finally, ensure that both you and your healthcare provider sign the application to certify its accuracy before submitting it via fax or email.

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