Get Enrollment Application For The Novartis Patient Assistance Foundation Inc

The Enrollment Application for the Novartis Patient Assistance Foundation Inc is an essential document for individuals seeking assistance with their medications. This guide provides clear, step-by-step instructions to help users successfully complete the form online.

Follow the steps to complete your Enrollment Application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the Patient Section on page 2. This includes providing your name, address, and financial information, such as your total gross monthly income. Be sure to attach a copy of your most recent year tax returns as proof of income.
3. Indicate whether you are a U.S. resident, provide your contact information, and answer questions about your veteran status and disability status.
4. List all sources of income and the number of people living in your household. Include details about any children and adults.
5. Have your healthcare provider complete and sign the Prescription Section on page 3. This includes important information about the medications prescribed and the provider’s certification.
6. Review the checklist to ensure that all necessary sections are completed, including signatures from both yourself and your healthcare provider.
7. Once everything is complete, save your changes. You can print or download the form for mailing or faxing.
8. Mail the form and supporting documents to the specified address or fax them from your healthcare provider's office.

Start filling out your Enrollment Application online today to take the first step toward receiving assistance.