Get Abbott Laboratories Patient Assistance Program Application Form

Filling out the Abbott Laboratories Patient Assistance Program Application Form online can be straightforward with the right guidance. This comprehensive guide will walk you through each section of the form, ensuring that you provide all necessary information for a successful application.

Follow the steps to complete your application efficiently.

1. Click ‘Get Form’ button to access the Abbott Laboratories Patient Assistance Program Application Form and open it in your preferred document editor.
2. Part I of the form requires information from the prescriber. Ensure that the prescriber fills out their details, including state license number, DEA number, and office shipping address. They must also provide their signature and the date.
3. In Part II, begin with the Applicant Information section. Enter your contact information, including your Social Security number, date of birth, and current address. Remember, no PO Box addresses are allowed.
4. Next, complete the Financial Information section. Document your monthly household income accurately, listing all sources such as salary, pension, and any other relevant financial support. Ensure to include the total amount and the number of people in your household.
5. Attach required documentation for income verification. Acceptable documents include recent tax returns, W-2 forms, and pay stubs for all members of the household. Ensure these documents are current copies, as originals should not be submitted.
6. If applicable, provide information regarding Medicare or Medicaid coverage, indicating whether you have coverage and whether the requested medication is included.
7. Complete the Representative section if someone else will be discussing your application with Abbott. Ensure that this person is authorized to act on your behalf.
8. Carefully review the certification statement in the application, signing and dating where indicated to confirm that the information is accurate and complete.
9. Once all sections are filled out, save the changes in your document. You may choose to download, print, or share your completed application with the necessary documentation for submission.

Start your application online today to access the Abbott Laboratories Patient Assistance Program.