Get Bristol Myers Squibb Patient Assistance Form 2020-2025
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How to fill out the Bristol Myers Squibb Patient Assistance Form online
Completing the Bristol Myers Squibb Patient Assistance Form is a crucial step for individuals seeking assistance with medication costs. This guide aims to provide you with clear, step-by-step instructions for filling out the form accurately and efficiently.
Follow the steps to complete the form seamlessly.
- Press the ‘Get Form’ button to access the Bristol Myers Squibb Patient Assistance Form online and open it within your document editor.
- In the Patient Information section, enter your first name, last name, middle initial, date of birth, and living address. If your mailing address differs from your living address, provide that as well.
- Fill out your Social Security Number and phone number. Indicate your gender and the name of a contact person, if necessary.
- In the Patient Eligibility Information segment, include total annual household income alongside documentation supporting this figure, such as your Federal tax form or other income proofs.
- Specify your household size, indicating the number of people living with you, and answer the questions regarding your insurance coverage, including public assistance programs.
- Sign the attestation statement, confirming that all information is accurate and that you meet the eligibility criteria for assistance from the program.
- Proceed to the Healthcare Provider Information section, where the prescribing practitioner will need to include their details, including name, professional designation, state license number, and shipping address.
- Identify the requested medication by selecting from the available options, noting the required quantity per day.
- If applicable, indicate whether this is a change to the dosing schedule for an existing patient and complete the required signature sections for both the patient and healthcare provider.
- Finally, ensure the entire application is complete. Save your completed form, download a copy, and either print it or share it as instructed for submission via mail or fax.
Complete your Bristol Myers Squibb Patient Assistance Form online today to start the process.
It is crucial to adhere to your prescribed medication schedule, as going without your medication can affect your health. Generally, the specific duration depends on the medication you are taking and your health condition. If you are concerned about affording your medication, consider using the Bristol Myers Squibb Patient Assistance Form to explore your options for continued access to your prescribed treatment.
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