Get Allergan Patient Assistance Program Application - Rxresource.org - Therxconnect

Completing the Allergan Patient Assistance Program Application can be straightforward with the right guidance. This guide provides step-by-step instructions to ensure the application process is clear and accessible for all users.

Follow the steps to successfully complete the application.

1. Click the ‘Get Form’ button to access the application form. This will allow you to open it in your preferred editor for completion.
2. Fill in the patient details section at the top of the form, including the patient's name, date of birth, social security number, telephone number, and the number of persons in the household.
3. Enter the gross annual household income and attach a copy of the most recent income verification, such as a tax return or pay stub.
4. Indicate the patient's insurance status by checking the applicable boxes for any insurance programs they are enrolled in, and specify if the medication is covered under these plans.
5. Sign and date the application in the designated patient signature section to certify that all information provided is accurate and that you will not seek reimbursement for the medication.
6. Ensure a healthcare provider signs below the patient signature if they are verifying income in lieu of documentation.
7. Finally, review the entire application for completeness, then save the changes. You can choose to download, print, or share the completed application as needed.

Start filling out your application online today to access the assistance you need.