Epilepsy Association of Utah

MAP Application

Please be sure to fill out all required fields.

NOTE: Depending upon when your request is received, it can take up to 8 weeks for the EAU to ascertain your eligibility for the program.

Fields marked with an * are required

Please have your Doctor sign the Statement of Need - download at the completion of this application.

In offering assistance and funding for AEDs the Epilepsy Association of Utah is not a medical provider or affiliated with any specific drug company. We do not prescribe medications or have an affiliation with any local or government entity. The Epilepsy Association of Utah is not liable for any fraudulent claims or misuse of prescription drugs acquired through this program. If fraudulent claims are discovered, you will be cut from the program and reported to the proper authorities. No cash will be given for AEDs. It will be handled at the pharmacy filling your prescription. By signing this application you agree to hold the Epilepsy Association of Utah harmless for any and all problems that may arise through your improper use of the program. This application will not be considered for payment without a current paystub or a statement from the Social Security Administration. In signing and submitting this form, you agree to provide the original receipt for the item purchased within 30 days.