Get Lilly Patient Assistance Printable Forms

This guide provides clear and supportive instructions on filling out the Lilly Patient Assistance Printable Forms online. Follow each step carefully to ensure a smooth application process for receiving medications through the Lilly Cares Program.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the Patient Section by providing your personal information, including your name, address, and contact details. Make sure to accurately input your birth date and indicate your preference for receiving text messages regarding your application.
3. Fill in the Patient Income Information section, detailing the number of family members living in your household and your total gross household income. Gather necessary proof of income documents, such as tax returns or current pay stubs, ensuring you send copies only.
4. Review the Patient Certification section. Carefully read the statements and, if you agree with them, sign and date the section at the bottom.
5. Provide the necessary information in the Doctor Section. Have your doctor fill in their details, including name, address, phone number, and any required confirmations and agreements related to the prescription.
6. Ensure both you and your doctor have signed the necessary sections. Double-check for any missing information or required signatures before finalizing your application.
7. Once completed, save the form and its data. You can download, print, or share the application as needed. Make sure to keep copies of all submitted documents for your records.

Begin your application for the Lilly Patient Assistance Program online today.