Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editing tool.
2. Begin by filling out the physician information section. Clearly provide the physician's name, shipping address (not a P.O. Box), city, phone number, state, and zip code.
3. In the prescription information section, write the patient's name, the product requested, dosage, and quantity. Note that a four-month supply will be provided unless specified otherwise.
4. Document the state license number and include the physician's signature, indicating their understanding of medication use and terms outlined. Remember, only original signatures are acceptable.
5. Proceed to the patient information section. Clearly print the patient's name, Social Security Number (SSN), address, city, state, date of birth, number of people in the household, contact number, and zip code.
6. Specify the total monthly household income in the designated field. This figure includes the income of all individuals residing in the household.
7. Answer the insurance information questions. Confirm if the patient is covered by Medicare and, if applicable, whether the patient has prescription coverage. Provide the name of the coverage, if relevant.
8. In the patient authorization and certification section, fully read and understand the authorization statement, then sign and date the application, ensuring all information is true and complete.
9. Once all sections are filled out, review the form for accuracy. Save the changes, and choose whether to download, print, or share the completed application as per your requirements.

Complete your Lilly Cares application online today to access the assistance you need.