Maryland Prescription Drug Affordability Board

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Patient Drug Submission Forms

Instructions

What is the purpose of these forms? 

  • The Prescription Drug Affordability Board (PDAB) encourages individuals to report drug price increases and affordability issues with prescription drugs. 
  • These forms will be used to gather information  to assist the Board in identifying prescription drugs to study and to connect PDAB with members of the public who would like assistance in affording their drug. 
  • Each form is for one specific drug. You may submit multiple forms if you are having affordability challenges with multiple drugs. 
  • You may submit the quick submission form or the full submission form as explained below. 
  • The PDAB values your experience and insight. 

 
The PDAB has two Patient Drug Submission Form Options:

  • Quick Submission: This is a shortened survey (1 minute) designed to obtain minimal information from consumers experiencing drug affordability issues. This form does not ask for any identifying information.
  • Full Submission: This is a longer survey (5 minutes) designed to obtain more detailed information from consumers experiencing drug affordability issues. Use this form if you would like the PDAB to reach out to you and provide patient assistance. Identifying information is optional in this form. 

 
There are four ways to complete and submit the PDAB Patient Drug Submission Forms:

  1. Click the link and complete the google form on the Board's website pdab.maryland.gov for either the quick submission or full submission (electronic submission)
  2. Choose the fillable PDF for the Quick or Full Submission forms- complete the form and email to access.pdab@maryland.gov
  3. Print the PDF- complete the form and mail to:
    Maryland Prescription Drug Affordability Board
    16900 Science Drive, Suite 112-114
    Bowie, MD 20715
  4. ​Patients may also email access.pdab@maryland.gov or call PDAB staff (410-702-4981) to have a form sent via USPS.

DISCLAIMER: Information submitted on this form is a public record subject to disclosure under the Public Information Act (PIA). Certain information including sociological and medical information may be withheld or redacted in compliance with the PIA and applicable regulations.​