Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to obtain the application form and open it for completion.
2. Begin by providing patient general information. Include details such as the patient's name, mailing address, phone number, email (optional), gender, and date of birth. Ensure all entries are accurate and complete.
3. Indicate the follow-up point of contact in Line 5 on Page 2. Choose 'Provider' or another applicable option. If none is selected, the default is the provider.
4. Fill out the coverage information. Check each category that applies, such as Medicaid, Medicare, or private insurance. Ensure to note if the patient is enrolled, denied, or eligible.
5. If applicable, provide alternate shipping information for the medication. Ensure that the address is accurate and that all required fields are completed.
6. If an advocate is applying on behalf of the patient, provide their information in the advocate section and ensure to include a signature. If not, leave this section blank.
7. On Page 3, carefully review the 'Required Attachments' section and ensure that all necessary documents are prepared. Different programs may require different attachments.
8. Obtain the requisite signatures. Both the patient (or their legal representative) and the provider must sign on Page 4 to validate the application.
9. Once all sections are completed and accurate, save the changes. You can then download, print, or share the application as needed.

Complete the NASTAD Common Patient Assistance Program Application (HIV) online to access your health benefits.