Get Bausch & Lomb Patient Assistance Program

The Bausch & Lomb Patient Assistance Program is designed to provide prescription medications at no charge to eligible individuals who are uninsured or have been denied coverage. This guide will walk you through the process of completing the online form to apply for assistance.

Follow the steps to complete your application efficiently.

1. Press the ‘Get Form’ button to acquire the application document and open it for editing.
2. Fill in the practitioner’s information, including their name, address, city, state, zip code, license number, expiration date, fax number, and phone number.
3. Provide details for the patient, including their first name and last initial. Confirm that the patient meets the program's eligibility criteria, such as income limitations and lack of insurance.
4. Attach a completed prescription for the requested medication, ensuring it includes the original signature of the prescribing physician.
5. Review and check the appropriate medication(s) from the list provided, ensuring that only one bottle of each product is specified.
6. Sign the form as the patient to verify that all information is accurate and that you agree to the terms outlined regarding reimbursement and program usage.
7. Include the date next to the patient signature. Make sure that original signatures are included as copies are not acceptable.
8. Once the form is complete, you have the option to save changes, download, print, or share the application for submission.

Begin completing your application documents online today.