Get Veltassa Patient Assistance Program

This guide provides clear instructions for properly completing the Veltassa Patient Assistance Program form online. By following these steps, you can ensure that all necessary information is filled out correctly to support your application process.

Follow the steps to fill out the Veltassa Patient Assistance Program form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Fill in all relevant patient information, including the patient's name, date of birth, mailing address, and contact information. Ensure that all fields are completed, as incomplete forms may delay processing.
3. Provide comprehensive insurance information. Attach copies of both sides of the patient’s insurance card if applicable. Make sure to specify if the patient is uninsured.
4. Detail the prescribed dosing and indicate whether the patient will receive the Veltassa Start Program, which offers a 15-day trial for new patients. Select the appropriate starting dose and select the dispensing options.
5. Ensure that the prescribing physician signs and dates the prescriber declaration section, verifying the accuracy of information provided and the necessity of the prescription.
6. If applicable, have the patient or their representative sign the Privacy Notice and Patient Authorization, giving consent for Relypsa to use their health information as outlined.
7. Complete the optional Patient Assistance Program section if financial assistance is needed. Provide verification documentation for household income as outlined in the application.
8. Review the completed form for any errors or omissions, ensuring all necessary signatures are included. Once finalized, fax all pages of the form to the designated number, 1-888-623-7092.

Start filling out the Veltassa Patient Assistance Program form online today to ensure a smooth application process.