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  • Enrollment Form Directions For Patients -

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PATIENT ASSISTANCE PROGRAM (PAP) PATIENT ENROLLMENT FORM INSTRUCTIONS. Thank you for your interest in applying to The Safety NetFoundation, a nonprofit organization that helps qualifying patients.

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Quick Start may be able to provide DUPIXENT at no cost to help bridge patients to therapy if there is a coverage delay.

What is CABENUVA? CABENUVA is a complete prescription regimen used to treat HIV-1 infection in people 12 years and older who weigh at least 77 lbs (35 kg), to replace their current HIV-1 medicines when their healthcare provider determines they meet certain requirements.

Complete, sign, and electronically submit all pages of this form and applicable corresponding documents (including the prescription) through the portal, or fax to 1-844-208-7676 (toll-free). For assistance, please call 1-844-588-3288 (toll-free), Monday through Friday, 8am to 11pm (et).

What Is ViiVConnect? ViiVConnect provides comprehensive information to help healthcare professionals, pharmacists, patient representatives, and patients explore ways to access prescribed ViiV Healthcare medications.

CABENUVA is used to treat Human Immunodeficiency Virus (HIV) infection in adults aged 18 years and over. CABENUVA does not cure HIV infection; it keeps the amount of virus in your body at a low level. This helps maintain the number of CD4+ cells in your blood.

CABENUVA Savings Program helps eligible enrolled patients with their out-of-pocket costs for CABENUVA for up to $13,000 every calendar year. Medicare-eligible patients and patients enrolled in government-funded programs are not eligible for the CABENUVA Savings Program.

The bottom line Apretude is an injectable medication that you receive every 2 months to help prevent HIV. Cabenuva is a combination medication that's used for HIV treatment, and it consists of two back-to-back injections on the same day every 1 to 2 months.

CABENUVA may be covered under Medicare Parts B, C, or D, depending on your Medicare plan. With Medicare Part B, you may be responsible for 20% of the Medicare-approved amount. Secondary payers often help cover this coinsurance payment.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232