Get Enrollment Application For The Novartis Patient Assistance - Rxassist

The Enrollment Application for the Novartis Patient Assistance Foundation is designed to assist individuals in accessing necessary medications. This guide offers a detailed, step-by-step approach to completing the form online, ensuring clarity and support for all users.

Follow the steps to fill out the application effectively.

1. Press the 'Get Form' button to obtain the Enrollment Application for the Novartis Patient Assistance - Rxassist. This will allow you to open the form in an editable format.
2. Begin by entering your personal information in the Patient Section. Fill in your name, address, city, state, zip code, and phone number. Include your cell phone number and email address.
3. Provide accurate financial information. Attach a copy of your household’s most recent year tax returns and list all sources of gross monthly income, including salary, pensions, social security, and any other relevant benefits.
4. Indicate the number of people living in your home, specifying the number of adults and children. Confirm your status as a US resident and provide details regarding your veteran status and disability status, as applicable.
5. Complete the Patient Insurance Information section. Include a copy of the front and back of your insurance card, and fill in the required medical coverage details.
6. Read and sign the Patient Authorization section. Ensure you understand the permissions you are granting, with complete transparency about how your data will be used.
7. The Health Care Professional section must be completed by your healthcare provider. Provide them with the form to fill out their required information, including their name, contact details, and the specifics about the prescribed medication.
8. Once the form is fully completed and signed, you should review all information for accuracy. Ensure it is dated and includes all necessary signatures.
9. When the application is complete, you have two options for submission: either mail the application along with the required financial documentation or fax the application from your healthcare professional's office.
10. After submission, you will receive a letter regarding your application status. For any questions, you can contact the Novartis Patient Assistance Foundation.

Take action now and complete your Enrollment Application online to access the assistance you need.