Bausch Foundation
Medical Mission Program Application
Rx Pack
Please note, you must complete the forms and submit them properly before your application is complete. Expedited service to meet travel deadlines and deliveries to Alaska and Hawaii incur additional charges.
Partner Organization Information
Click on the buttons below to complete each form separately or select the bottom link to complete both. Both the Eligibility Packet (Partner Organization Information) and Practitioner's Agreement must be completed before shipments are approved.
Eligibility Packet Form
Practitioner's Agreement Form
Eligibility Packet with Practitioner's Agreement
Please complete, sign and submit the following 4 forms and a member of the MAP Team will be with you shortly. Please note, you must complete all 4 forms and submit them properly before your application is complete. Expedited service to meet travel deadlines and deliveries to Alaska and Hawaii incur additional charges.