Follow the steps to complete your application online

1. Click ‘Get Form’ button to access the application and open it in your preferred editor.
2. Begin by entering your personal information. Fill in your full name, date of birth, address, city, state, ZIP code, and phone number in the specified fields.
3. Provide your valid email address, which allows the program to communicate with you digitally.
4. Indicate your gender by selecting the appropriate checkbox.
5. Specify your residency status by checking one of the following options: U.S. Citizen, Legal Resident, or Work Visa. If you select Work Visa, ensure that you attach a copy.
6. Enter your annual household income and provide supporting documentation as instructed based on your application timeline.
7. Indicate the number of family members in your household, including yourself.
8. Confirm if you have no health insurance coverage that pays for by checking the designated box.
9. Move on to the medical questions section. List any medications you are taking and any allergies to medications.
10. Include details about any medical conditions you have by filling out the relevant spaces or checking the box if there are none.
11. Read and acknowledge the agreement by signing and dating the application. Your signature confirms the accuracy of the information provided.
12. If applicable, list names of individuals to whom you are granting permission to act on your behalf.
13. Compile the necessary documents, including your driver’s license or state photo ID, and ensure the prescriber has signed and completed their section.
14. Submit your completed application by mailing it to the address provided or by having your prescriber fax it. Remember to keep a copy for your records.

Take the first step now by filling out your Patient Assistance Program application online.