Get Form For Patient Assistance Program (pap) - Rxassist - Rxassist

Filling out the FORM for the Patient Assistance Program (PAP) is essential for individuals seeking assistance with medication access. This guide provides a clear and comprehensive approach to completing the online form effectively.

Follow the steps to fill out the Patient Assistance Program (PAP) form.

1. Press the ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin by entering your personal information in the 'Patient Information' section. Fill in your name, shipping address (note that P.O. boxes are not permitted), city, state, zip code, and phone number.
3. Provide your Social Security Number and date of birth. Then indicate your gender by selecting either 'Male' or 'Female'.
4. If applicable, specify a patient representative who may discuss this form with the program. Include their name, relationship to the patient, and phone number.
5. Answer the residency question by selecting 'Yes' or 'No' as to whether the patient is a U.S. resident.
6. Detail the patient's drug coverage. Indicate if covered by a private plan, Medicare, or other government coverage and fill in the corresponding information.
7. Report the yearly household income, including all sources such as wages and benefits.
8. State how many people live in the household by circling the appropriate number.
9. Ensure to attest the accuracy of the provided information by signing and dating the form.
10. Provide the prescribing practitioner information, including their name, address, phone number, and National Provider Identifier (NPI).
11. Complete the prescription information section including the medication quantity, dosage, and any allergies or other medications.
12. The prescriber must sign and date the form to finalize it before submission.
13. After completing all sections, save changes to the document, and download or print the form. If necessary, share it with relevant parties.

Take the first step toward accessing assistance by completing the Patient Assistance Program (PAP) form online today.