Follow the steps to complete your application accurately.

1. Click the ‘Get Form’ button to obtain the application form and open it in the designated editor.
2. Section 1 requires you to provide detailed physician and prescription information. Ensure that all fields for the physician's name, contact details, and prescription details are filled out accurately. Remember that a physician's signature is necessary to validate this section.
3. In Section 2, complete all fields regarding patient information. This includes the patient's name, social security number, address, date of birth, and household information. Ensure to indicate if the patient is a U.S. resident and if they are a veteran.
4. Section 3 asks for detailed financial information, including all sources of income. Attach proof of income, such as the most recent federal tax return or other specified documents, to validate eligibility.
5. In Section 4, complete the Social Security Low Income Subsidy section. If applicable, attach the denial letter if the subsidy was requested and denied within the past year.
6. Section 5 requires you to provide details on prescription drug coverage. Fill out the insurance fields and indicate the total amount spent on prescriptions since January 1 of the current calendar year. Make sure to attach appropriate documentation as proof.
7. Finally, complete Section 6 by signing the patient attestation. The patient's signature is essential for the eligibility determination. Ensure that all sections have been filled out to avoid delays.
8. Once all sections are completed, save any changes, and download, print, or share the completed form as needed.

Start your application online today to access the Boehringer Ingelheim Patient Assistance Program.