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Get Actavis Patient Assistance Program
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How to fill out the Actavis Patient Assistance Program online
The Actavis Patient Assistance Program helps individuals access medication they may not be able to afford. This guide provides clear and detailed instructions for completing the application form online, ensuring you submit a complete and accurate application.
Follow the steps to effectively complete the application form.
- Click ‘Get Form’ button to obtain the application form and open it for editing. Ensure you have all necessary information ready before proceeding.
- Fill out Section 1.0 with the licensed prescriber information, including first name, last name, professional designation, and contact details. Make sure to provide a valid prescription attached to the application.
- Proceed to Section 2.0 to provide patient information. Fill out the patient’s legal name, date of birth, gender, and contact details. You will also need to confirm US residency status and marital status.
- In Section 2.1, enter all sources of income. Include salary, Social Security, and any other financial support to determine total gross monthly income.
- Continue to Section 2.2 to provide other coverage information. Indicate if the patient has VA benefits, Medicare, or Medicaid. Be sure to include information about any private prescription coverage.
- In Section 3.0, the patient must sign and date the certification, affirming the accuracy of the provided information and acknowledging the terms of the assistance program.
- Licensed prescriber must complete and sign Section 4.0 with their details and certification. Ensure the prescriber’s signature aligns with the prescription provided.
- Before submitting, attach all required documents, including proof of income and, if applicable, a Medicare Part D Low-Income Subsidy denial letter.
- Once all sections are filled out and documents are attached, save any changes to the form. You can choose to download, print, or share the completed application form as necessary.
Get started with your application for the Actavis Patient Assistance Program online today!
Related links form
A copay assistance card (also known as a copay savings program, copay coupon, or simply a copay card) is essentially a coupon that makes a medication way less expensive for you. ... Instead of paying a high copay (perhaps $50, $75, or more, depending on the specifics of your insurance coverage), you pay a lot less.
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