Get Lilly Cares Form

The Lilly Cares Form is essential for individuals seeking assistance with Taltz therapy. This guide provides a step-by-step approach to effectively complete the form online, ensuring accurate submission and support.

Follow the steps to successfully complete the Lilly Cares Form.

1. Press the ‘Get Form’ button to retrieve the Lilly Cares Form and open it in your document editor.
2. Fill in the patient’s name in the designated field labeled 'Patient Name.'
3. Enter the date of birth in the 'Date of Birth' section to clearly identify the patient.
4. Provide the complete address of the patient in the 'Address' field.
5. Input the patient's telephone number where indicated to facilitate contact.
6. Authorize Lilly Cares to transmit the prescription by checking the appropriate box for the medication, TALTZ (ixekizumab).
7. Choose the patient's treatment plan by selecting either 'Autoinjector' or 'Prefilled Syringe' in the Injection Device section.
8. Indicate the starting dose and first two induction doses by selecting the relevant options provided in the form.
9. Specify where to ship the starting dose and two induction doses, choosing either to the physician's address or the patient's address.
10. Outline the remaining induction doses and the maintenance dose as per the options listed, ensuring accurate quantities.
11. Fill in the refills section based on treatment needs, choosing the appropriate option for duration.
12. Sign and date the form as required by the prescriber, ensuring compliance with state laws.
13. Complete the prescriber’s details, including the printed name, title, state license number, and contact information.
14. Review all fields for accuracy before saving changes, downloading, printing, or sharing the completed form.

Proactively complete your Lilly Cares Form online today to ensure timely assistance.