Get Actavis Pharma Inc Patient Assistance Program Attach Valid Bb - Pparx

This guide provides a clear, step-by-step process for filling out the ACTAVIS PHARMA INC Patient Assistance Program Attach Valid Bb - Pparx online. It is designed to assist users in completing the application accurately and efficiently, ensuring that all necessary information is submitted for the program.

Follow the steps to successfully complete your application

1. Click ‘Get Form’ button to access the application and open it for completion.
2. In Section 1.0, enter the licensed prescriber's personal information, including their first name, last name, state license number, DEA number, mailing address, office contact name, and phone number.
3. For Section 2.0, provide the patient’s personal details such as their first name, last name, gender, social security number, date of birth, mailing address, marital status, email address, and household information.
4. In Section 2.1, input the patient’s income information, including salary, social security, alimony, and total gross monthly income.
5. Section 2.2 requires users to detail any additional coverage, such as VA benefits, Medicare, or Medicaid information, and necessary identification numbers.
6. Patient must sign and date Section 3.0 to certify their inability to pay for the requested medication and ensure honesty in their provided information.
7. The licensed prescriber must complete Section 4.0 by signing and dating to confirm their authorization to prescribe the requested medication.
8. Attach all required documents, including the prescription, proof of income, and any relevant denial letters. Ensure all documentation is signed and valid.
9. Review the completed application for accuracy before submitting. Users can then save changes, download, print, or share the form as necessary.

Complete your ACTAVIS PHARMA INC Patient Assistance Program application online today!