Get Kowa Pharmaceuticals Patient Assistance Program

This guide provides clear instructions for completing the Kowa Pharmaceuticals Patient Assistance Program form online. By following these simple steps, users can easily navigate the process to ensure they provide all necessary information for their application.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access and open the Patient Assistance Program application form.
2. Fill out the Patient Information section with your first name, middle initial, last name, mailing address, city, state, postal code, Social Security number, phone number, and any contact person if different from you. Additionally, list any drug allergies and current medications.
3. Provide your total annual household income in the designated field, ensuring that you include all sources of income. Specify the household size, and indicate whether you are enrolled in a Medicare Part D Prescription Drug Plan, as well as any other public or private prescription drug coverage.
4. Read and understand the attestation statement regarding the completeness and accuracy of your information. Provide your signature and the date to confirm your agreement.
5. The healthcare provider must complete and sign the Healthcare Provider Information section, which includes their name, facility name, address, phone number, and NPI number.
6. Select the requested medication and specify the quantity for a 90-day supply. The healthcare provider's signature is required here to validate the prescription.
7. Complete the Authorization to Use or Disclose Health Information section. This step allows the necessary use and disclosure of your health information for program participation.
8. Review the form thoroughly to ensure all fields are completed correctly. Finally, save your changes, then download, print, or share the completed form as needed.

Complete your Kowa Pharmaceuticals Patient Assistance Program application online today!