Get - Abbvie Patient Assistance Foundation

The AbbVie Patient Assistance Foundation provides critical medication assistance to individuals facing financial barriers to accessing necessary treatments. This guide explains how to fill out the application online, ensuring you understand each section's requirements to facilitate a smooth submission process.

Follow the steps to successfully complete the application form.

1. Press the ‘Get Form’ button to acquire the application form and open it in your preferred editor.
2. Complete the physician information section on the first page. Be sure to include the physician's name, contact details, and state license number. This ensures that the prescribing physician is properly identified.
3. Fill out the patient history and shipping preference section. Include details such as the patient's name, date of birth, and any known allergies. Specify the desired shipping address for the medication.
4. Enter the prescription information, including the specific medication being requested () and appropriate diagnosis codes. Provide directions for use, quantity to be dispensed, and any special notes, particularly if you are in New York.
5. Have the prescribing physician sign and date the certification section at the bottom of the first page. This signature is crucial for processing the application.
6. Complete the patient information section on the third page. This includes the patient’s demographics, contact information, details about treating physicians, and medication usage.
7. Fill out the insurance information section, indicating whether you have insurance coverage or not. If you do, include the necessary details about your primary and secondary insurance.
8. Provide your financial information, including current household income and documentation if applicable. Make sure to verify the accuracy of any information submitted.
9. Complete the patient certification and authorization section. This involves signing and dating the document to confirm your understanding of the terms.
10. Once filled out completely, review the application for errors or missing information. Then you can choose to save changes, download, print, or share the completed form as needed.

Start your application now to receive necessary medication assistance from the AbbVie Patient Assistance Foundation.