Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the application form and open it in your chosen tool.
2. Begin by filling out the patient information section. Input the patient's name, date of birth, address, city, phone number, alternative phone number, state, and zip code.
3. Next, provide the patient's annual income, including all sources such as social security and pension benefits, along with supporting documentation like W2 forms or 1099 statements.
4. Indicate the product use by confirming that it is consistent with the FDA-approved indication for RADIESSE, specifically for the restoration and/or correction of facial fat loss in individuals living with HIV.
5. Answer whether the patient qualifies for insurance coverage under a public program. If 'yes,' the patient is not eligible for the assistance program.
6. In the patient statement and authorization section, the patient must read and understand the consent statement before signing and dating the form.
7. Check the box if the patient consents to being contacted directly by Merz.
8. Then, proceed to fill out the practice information section by entering the physician’s name, specialty, facility name, and other relevant details, including contact information.
9. Provide necessary identifiers such as DEA number, NPI number, state license, and office contact information.
10. Specify the number of syringes requested, selecting from the available options.
11. Have the licensed practitioner complete their statement by confirming the administration of RADIESSE only to the patient listed, and sign and date the form.
12. Finally, save your changes, download or print the completed form, and ensure to share it as required.

Complete your Radiesse Patient Access Program application online today for efficient processing.