Get Arch Patient Assistance Program Application Form... - Public Health Oregon

The ARCH Patient Assistance Program Application Form is designed to assist individuals who do not have access to adequate insurance coverage for products like and Skyla. This guide provides a clear step-by-step process to help you fill out the application accurately and effectively.

Follow the steps to complete your application.

1. Press the ‘Get Form’ button to download and open the ARCH Patient Assistance Program Application Form in your preferred digital editor.
2. Begin filling out the provider information section, which must be completed by the healthcare provider. Include the provider's name, facility name, address, contact information, and state license number.
3. Complete the patient information section, ensuring you provide the patient's name, address, phone number, and any known drug allergies.
4. Fill out the prescription information, including the date, patient’s name, date of birth, product selection (choose between or Skyla), quantity, refills, and special instructions.
5. In the provider declaration and authorization section, the healthcare provider must confirm the accuracy of the information provided and sign with the date.
6. Provide the coverage and insurance information, indicating whether the patient has Medicaid or any other form of private or public insurance coverage, along with reasoning if applicable.
7. In the financial information section, report the current annual household income and number of household members dependent on that income. Include proof of income documentation or select the certification option.
8. Complete the proof of income certification if opting for healthcare provider or administrator certification, ensuring their signature, name, title, and contact number are included.
9. For the applicant declaration, the patient or their representative must sign and date the application while confirming that all information is complete and accurate.
10. Verify that all sections of the form are completed and that all required documentation is included before finalizing your submission.
11. Submit the completed application and documentation to ARCH via mail or fax, as per the instructions provided at the beginning of the form.

Complete your ARCH Patient Assistance Program Application Form online today to take advantage of available support.