Get Actavis Pharma, Inc. Patient Assistance Program ... -

This guide provides clear, step-by-step instructions on how to effectively complete the ACTAVIS PHARMA, INC. Patient Assistance Program application online. By following these instructions, users will be able to successfully navigate the application process and submit their forms with confidence.

Follow the steps to complete your application seamlessly.

1. Press the ‘Get Form’ button to access the application form and open it for editing.
2. Fill in SECTION 1.0 with the licensed prescriber information. Include their first name, middle initial, last name, professional designation, state license number, DEA number, mailing address, delivery address, office contact name, phone number, and NPI number. Ensure that valid prescriptions are attached.
3. Complete SECTION 2.0 with the patient’s information. Provide the patient's first name, middle initial, last name, gender, date of birth, phone number, social security number, mailing address, email address, and confirm their citizenship status.
4. In SECTION 2.1, enter the income information including salary, social security, alimony, disability, pension, and total gross monthly income.
5. Fill out SECTION 2.2 regarding other coverage information. Indicate whether the patient has VA or military benefits, Medicare enrollment, Medicaid enrollment, and private prescription coverage.
6. In SECTION 3.0, the patient must sign and date the certification indicating their financial need and understanding of the program. Ensure the signature is valid for twelve months.
7. Have the licensed prescriber complete SECTION 4.0 by signing and dating the certification. This certification also needs to be valid for twelve months.
8. Gather all additional documents required, including the prescription, proof of monthly household income, and photocopy of any necessary denial letters.
9. Review the completed application for any mistakes or missing information. Once verified, submit the application along with all attachments as instructed.
10. After submission, be prepared to wait approximately four weeks for processing. At this point, users will also have the option to save changes, download, print, or share their completed application for records.

Start your application process online today to gain access to assistance with your medications!