Follow the steps to complete your application easily and efficiently.

1. Press the ‘Get Form’ button to acquire the application form and open it in your preferred document editor.
2. Complete the Patient Section by providing your name, address, contact information, and date of birth. Ensure all provided details are accurate and up-to-date.
3. Fill in the Patient Income Information, including the number of household members and your total gross household income. Verification documents must be selected and prepared for submission.
4. Carefully read the Patient Certification section and ensure that all statements regarding eligibility are true. Sign and date where indicated to affirm your understanding.
5. Have your doctor complete the Doctor Section. This includes providing their name, address, phone number, and necessary confirmations. Ensure they sign and date the requirement.
6. Prepare copies of proof-of-income documents as outlined in the form. Remember to keep originals for your records while only sending copies.
7. Once all sections are completed, save your document. You can print the application and proof-of-income documents or opt to fax them directly to the Lilly Cares program at the provided fax number.

Begin your application process online to ensure you receive the support you need.