Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the application online. This will allow you to open the form in your chosen editor, where you can begin the completion process.
2. In the Patient Section, enter the patient’s name, address, city, state, zip code, and phone number. Ensure all information is accurate and complete.
3. Provide financial information by attaching copies of your most recent tax returns, ensuring not to send original documents. Indicate total household income and household composition.
4. Mark whether the patient is a U.S. resident and indicate their gender, veteran status, and whether they have a disability.
5. List all sources of gross monthly income, including salaries, social security benefits, and other pertinent financial details.
6. Complete the insurance information by including copies of the front and back of the prescription and insurance cards. Fill in the necessary relevant details.
7. Sign the Patient Authorization section, date it, and ensure that this signature is completed by the patient or their legal guardian.
8. In the Prescription Section, your healthcare professional will need to fill out and sign their section. Ensure they provide all necessary information accurately.
9. Review your completed application thoroughly, making sure all sections are filled and all required documentation is attached.
10. Once everything is complete, either mail or fax the application along with the required documentation to the Novartis Patient Assistance Foundation using the provided contact information.

Complete your 18002772254 form online now and take the first step towards accessing your needed medications.