Get ready to apply
Good Days
Acute Lymphoblastic Leukemia Copay Assistance
What you get
Help paying treatment copays and coinsurance for acute lymphoblastic leukemia. The amount isn’t published. Ask. Applications are closed for now. Ask when they reopen.
- Who starts it
- You
- How it’s sent
- PDF form, sent the way they ask
- Your time
- About 30 minutes
- Last checked
- Aug 27, 2026
Before you start, check you fit
- Some programs may be seasonally closed, waitlisted, provider-gated, hospital-gated, or past for the current cycle.
- You need to show financial need.
-
What their form asksA preview, so you can gather things first. Fill it in on their site.
Open the application PDF ↗ Checked Aug 27, 2026What the form asks for
Good Days Patient Enrollment ApplicationNameDate of BirthSSNGenderMailing AddressPhoneEmailAlternate Contact InformationAnnual Household IncomeNumber of People in HouseholdProvider NameProvider PhoneDiagnosisMedication(s)Pharmacy NamePrimary Insurance NamePrimary Insurance Member IDIs this a Medicare, Military or Federal Employee insurance planSecondary Insurance InformationHow did you hear about usSignature of Individual or Individual’s representativeDateHave ready
- Front and back copies of the patient insurance cards.
- One approved household-income document if Good Days requires documentary verification.
- Pages 3-5 completed, signed, and dated where applicable.
After you send
Save a copy and confirmation; check status in the Good Days portal or call a Patient Care Navigator. If you have not heard back in two weeks, write and ask whether it arrived.