Get Coupon

Filling out the Coupon for the Bayer HealthCare Patient Assistance Program is a straightforward process that helps individuals access important medications. This guide provides clear, step-by-step instructions to assist users in completing the form accurately, ensuring eligibility for assistance.

Follow the steps to complete the Coupon online.

1. Press the ‘Get Form’ button to access the Coupon. This will open the document in your preferred editor for completion.
2. Begin with Section 1 for healthcare provider information. Fill in the date, patient name, date of birth, prescriber’s name, and NPI number. Provide the facility name, address, city, state, and zip code. Include the contact name, title, and extension, along with the telephone and fax numbers.
3. In this section, select the product requested (®, ®, or ®) and enter the dispense quantity, usually a 90-day supply. Ensure that the prescriber’s signature and date are included at the bottom to confirm the application’s accuracy.
4. Proceed to Section 2 for patient information. Complete the patient's name, address, phone numbers, Social Security number, and email. Indicate the method of payment for the $15 shipping fee, checking the option for credit/debit or check. Record any known drug allergies and health conditions, along with marital status and income details.
5. Answer the eligibility questions, confirming residency in the U.S. or region, and status concerning government or private prescription programs. This information is crucial to determine eligibility for the program.
6. In Section 3, the patient or legal guardian must review and sign the consent and authorization, certifying the information provided is accurate and complete. This section ensures the release of necessary information to Bayer HealthCare for processing the application.
7. Once all sections are filled, check the application for completeness. Ensure all required documentation, including proof of income, is gathered. Then, fax or mail the completed Coupon to the designated contact information provided in the guidelines.
8. After submitting the application, wait for a response. Patients will be notified of approval or denial by mail, typically within 2 business days.

Complete your Bayer HealthCare Patient Assistance Program Coupon online today to access the medications you need.