Get Pre-exposure Prophylaxis

Filling out the Pre-Exposure Prophylaxis Drug Assistance Program application is an important step for individuals seeking assistance to access PrEP medication. This guide will help you navigate the process with clarity and confidence.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to obtain the Pre-Exposure Prophylaxis Drug Assistance Program application form and open it for filling.
2. Begin by completing Section 1, which covers applicant information. Ensure that you include your first name, middle initial, last name, and other personal details such as date of birth and social security number. Print clearly for readability.
3. Next, fill out Section 2 regarding your income information. Provide your current annual income and specify any sources of income you may have, as well as your employment status.
4. In Section 3, an optional part, you can designate an alternate contact who can discuss your application on your behalf, if desired.
5. Proceed to Section 4, which must be completed by your healthcare provider. Make sure they fill out the relevant provider information and patient risk category.
6. In Section 5, you will input your pharmacy information. Include the full name, address, and contact details of your preferred pharmacy.
7. In Section 6, specify your insurance coverage. Clearly mark the types of insurance you may have and include copies of your insurance cards.
8. Finally, in Section 7, review the certification statement. Sign and date the application to confirm that all provided information is accurate.
9. Once completed, save your changes, then download, print, or share the application as needed before submitting it via mail or fax.

Complete your Pre-Exposure Prophylaxis application online today for assistance.