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Get Patient Assistance Program
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How to fill out the Patient Assistance Program online
This guide provides comprehensive instructions on accurately completing the Patient Assistance Program form online. By following these steps, users can ensure their application is properly submitted and increases their chances of receiving assistance.
Follow the steps to complete the Patient Assistance Program form online.
- Click ‘Get Form’ button to obtain the Patient Assistance Program form and open it for editing.
- Begin by filling out the patient demographic information. Include the patient's full name, address, and date of birth. Be sure to indicate any allergies by circling the relevant options or writing in any other allergies.
- Provide the contact information, including the home phone number and indicate whether the patient is a citizen or permanent resident of the United States. Attach proof of residency if applicable.
- Complete the financial information section. Indicate the number of adults in the household and provide details of the patient’s income, spouse’s income, and other income sources. Attach proof of income as required.
- Document the diagnosis and any previous phosphate binder therapy. Make sure to answer questions regarding Medicaid coverage and Low Income Subsidy applications.
- Fill out the prescriber information section, including the full name, contact details of the prescriber, and the patient’s dialysis facility information.
- In the prescription information section, provide details about the prescribed drug, dosage instructions, and refills authorized by the prescriber.
- Obtain signatures for both the prescriber agreement and patient agreement sections, ensuring compliance with the requirements stated on the form.
- Before submission, review the application to ensure all required fields are completed and all necessary documents are attached, including proof of income and residency.
- Once completed, you can save your changes, download, or print the form for your records. Finally, fax or mail the application to the specified address.
Complete your Patient Assistance Program application online today to explore available support.
Eligibility for AbbVie's assistance typically includes individuals who are uninsured, underinsured, or facing financial hardships. Patients need to meet specific criteria outlined by the program to receive benefits. Utilizing a Patient Assistance Program like AbbVie’s can significantly improve access to vital medications and services.
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