Thank you for submitting your New Case Referral or Request for Case Information electronically. This site will allow you to provide vital patient information and attach any necessary documentation so that we can determine eligibility and set up a case. You will also have the ability to request information on an existing case. Our goal is to provide you a more timely response for your case and eliminate unnecessary phone calls, print and postage costs.

If you have an existing Username and Password, Log in here:


The Username (your email address) field is required.


The Password field is required.

Forgot your password? Click here.

Change your password. Click here.

New user? Create an account here.

If you are a member or received an Evaluation Letter with a Case number from us, please go to and input information.