Get Assistance Program

Filling out the Assistance Program application is a crucial step for individuals seeking help. This guide provides clear and concise instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully submit your assistance application.

1. Click ‘Get Form’ button to obtain the application form and open it in the online editor.
2. Begin by filling out the Healthcare Provider Information section. Enter the physician's name, address, and contact details. Ensure the DEA number is provided.
3. Complete the Medication Information section by indicating the requested product, which will be ®, and providing the patient’s diagnosis codes as required.
4. In the Patient Information section, enter the patient’s full name, address, phone numbers, date of birth, and other relevant information. Make sure to mark N/A for any applicable fields.
5. Fill out the Financial Information section, including total income and household details. Attach proof of income, which may include tax returns and pay stubs.
6. Complete the Insurance Information section, ensuring any insurance details are accurately filled in. Attach copies of the patient’s Insurance and Prescription Cards.
7. Review and sign the Applicant Declaration section, confirming the accuracy of the provided information. The patient or legal guardian must provide their signature and date.
8. Lastly, save your changes, and download, print, or share the completed form as needed.

Take action now and complete your application for the Assistance Program online.