Follow the steps to complete your application successfully.

1. Click the ‘Get Form’ button to access the Assistance Program application. This will allow you to open the form in an editable format.
2. Begin filling out Section 1, which collects information about the licensed prescriber. Provide the prescriber's first name, middle initial, last name, state license number, professional designation, DEA number, and mailing address, including city, state, zip code, and contact information.
3. Proceed to Section 2, where you will enter your personal information. Fill in your first name, middle initial, last name, phone number, gender, date of birth, mailing address, marital status, email address, and the number of people in your household. Indicate whether you are a veteran and if you have received disability payments for more than 24 months.
4. In Section 2.1, enter your income information. Each field, such as salary, social security, and other relevant income sources, should be completed with accurate values. Then, calculate your total gross monthly income.
5. Continue to Section 2.2, where you will provide information about any other insurance coverage. Answer the questions regarding VA or military benefits, Medicare enrollment, Medicaid enrollment, and any private prescription coverage you might have, along with pertinent details for each insurance plan.
6. In Section 3, sign and date the patient certification. Ensure that you understand the commitments and requirements outlined, such as verifying your information and agreeing not to seek reimbursement from other sources.
7. If you are filling it out on behalf of someone else, ensure that a signed and notarized Power of Attorney document is attached.
8. The licensed prescriber should complete Section 4, sign, and date it, as well as provide a prescription for the requested medication to attach to the application.
9. Compile all necessary documents, including proof of monthly income and any required letters, into a complete application package. Review the application to ensure it is filled out completely and accurately before submission.
10. Once everything is ready, save your changes, and either download, print, or share the completed form as needed for submission.

Start your application process online today to secure the assistance you need.