Get Abbott Patient Assistance Program Application

The Abbott Patient Assistance Program Application is designed to assist individuals in accessing necessary medications at little to no cost. This guide provides a clear and supportive approach to filling out the application online, ensuring all required information is accurately submitted.

Follow the steps to successfully complete your application online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing environment.
2. Begin with Part I, which includes the prescriber information. Fill in the prescriber’s last name, first name, professional designation, office shipping address, and contact details as required.
3. Next, provide the prescription information such as the product name, strength, and prescription details. Ensure the refills section is accurately completed.
4. Proceed to the certifications section where the prescriber needs to authorize the release of health information and verify the accuracy of the provided details. The prescriber must sign and date this section.
5. Move to Part II, the applicant information. The applicant or their representative must attest to this section. Input the applicant’s contact information, including their social security number and date of birth.
6. In the financial information section, attach the most recent income documents and indicate the number of people in the household along with total monthly income from various sources.
7. Fill in the prescription coverage information. Indicate whether the applicant has Medicare or other prescription coverage, and provide relevant details for verification.
8. If applicable, include details of a representative for the purposes of the program. Provide their name and relationship to the applicant.
9. Complete the certification section, where the applicant confirms their understanding of the program’s requirements, signs and dates the form.
10. Finally, review the completed application for accuracy. You can save changes, download, print, or share the form as needed.

Start filling out your Abbott Patient Assistance Program Application online today for assistance with accessing your medications.