Get Application For Astellas Access Programsm ... - Needy Meds - Needymeds

This guide provides step-by-step instructions on how to successfully complete the Application for Astellas Access Program for . By following these instructions, users can ensure they provide all necessary information accurately.

Follow the steps to complete the application effectively.

1. Click the ‘Get Form’ button to obtain the Application for Astellas Access Program. This will open the document for you to begin filling it out.
2. Enter the patient information in the designated fields including first name, last name, Social Security number, sex, city, state, ZIP code, and daytime and evening phone numbers.
3. Provide mailing and shipping addresses, filling in the city, state, and ZIP code for both sections.
4. Fill out the medical information section by indicating the transplant type and date, the entity that paid for the transplant, known allergies, and the date therapy began. Include the names of other immunosuppressive drugs the patient is currently taking.
5. Complete the insurance information table. Indicate the status of each applicable insurance type (such as Medicare B, Medicare D, Medicaid, private insurance, and other) and attach photocopies of the patient’s insurance cards.
6. In the financial information section, specify the size of the household, gross family annual income, and gross family annual medical expenses.
7. Read and acknowledge the patient authorization to disclose health information and enrollment in the Astellas Access Program. Ensure that the patient or guardian signs and dates the form, signifying understanding of the terms.
8. Provide physician information, including the physician's name, contact person, facility name, and contact details.
9. Insert the prescription information for , including strength, frequency, total daily dose, and any necessary refills. The physician must provide an original signature, as stamped signatures are not accepted.
10. Complete the physician certification and consent section, where the physician confirms the medical appropriateness of for the patient. The physician should also sign and date this section.
11. Review the completed application for accuracy. After ensuring all fields are filled correctly, you can save, download, or print the application.

Complete your application online to ensure timely processing.