Get Teva Assistance Program Enrollment Application Form

Filling out the Teva Assistance Program Enrollment Application Form online is a straightforward process designed to assist users in accessing vital medications. This guide will provide step-by-step instructions on completing each section of the application effectively.

Follow the steps to complete the application form accurately.

1. Click 'Get Form' button to access the Teva Assistance Program Enrollment Application Form and open it in your preferred document editor.
2. Complete Section 1 by providing the patient's name, date of birth, address, phone number, social security number, gender, residency status, household size, and total gross monthly household income, including all relevant sources.
3. Indicate the patient's insurance information, checking whether they have a prescription drug benefit and specifying the applicable programs by marking 'Yes' or 'No'.
4. In Section 1, ensure you attest the accuracy of the information provided by signing and dating the application.
5. Proceed to Section 2 to enter the attending physician's information, including name, shipping address, contact information, state license number, and NPI number.
6. Select the medication requested for the patient by marking the appropriate options. Confirm the selected therapy is necessary and has not been misappropriated.
7. Finalize the application by obtaining the physician's signature and date. Ensure that the application is accompanied by the signed Patient Authorized Release Disclosure of Medical Information form.
8. Once completed, save your changes, download the document, print it if necessary, or share it as required. Ensure that the application is submitted to the correct fax number provided in the instructions.

Start filling out your Teva Assistance Program Enrollment Application Form online today to access the support you need.