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Get Roche Patient Assistance Form
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How to fill out the Roche Patient Assistance Form online
The Roche Patient Assistance Form is an essential document for individuals seeking access to ACCU-CHEK® blood glucose test strips through the Patient Assistance Program. This guide provides a clear and step-by-step approach to filling out the form online, ensuring a smooth application process.
Follow the steps to successfully complete the Roche Patient Assistance Form.
- Click the 'Get Form' button to obtain the Roche Patient Assistance Form and open it.
- Complete Section 1: Patient Information. Provide your full name, date of birth, and address. Include your Social Security Number (SSN) and contact information. Additionally, indicate if you are a U.S. citizen and if you are a veteran or disabled. Also, list your household income and the sources of this income.
- Attach the necessary financial documentation, such as your most recent tax returns (1040, 1040A, SSA 1099). Ensure all required documents are included.
- Have your physician complete Section 2 of the form. This includes providing their contact information, licensing details, and a diagnosis code.
- Obtain a prescription for the requested product from your physician and ensure it is attached to the application.
- Review all completed sections for accuracy before proceeding to submit the application.
- Mail the completed application, financial documentation, and prescription to Roche Diagnostics Patient Assistance Program at the specified address.
- After mailing the application, you may receive a confirmation within one week regarding your eligibility. Keep track of your application for reference.
- Once approved, remember that reapplication is required after one year, and only a three-month supply of products will be shipped at a time.
Complete your Roche Patient Assistance Form online today to access the support you need.
The corporate address for Roche Diagnostics is located at 9115 Hague Road, Indianapolis, IN 46256. Patients and healthcare providers can reach out directly to this address for information. Additionally, for easier access to patient programs, it is beneficial to complete the Roche Patient Assistance Form.
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