Get Arch Patient Assistance Program Income Limits

This guide provides clear, detailed instructions on filling out the Arch Patient Assistance Program Income Limits form online. It is designed to assist users in accurately completing the application to ensure they can benefit from the program.

Follow the steps to successfully complete the Arch Patient Assistance Program form.

1. Click the ‘Get Form’ button to obtain the Arch Patient Assistance Program Income Limits form and open it in the editor.
2. Begin by completing Section A, which requires provider information. Include the provider's name, facility name, address, phone, fax, and email address. Indicate the clinical setting type by checking the applicable boxes.
3. In Section B, provide the prescription information. Enter the date, patient’s name, date of birth, and select the product you are prescribing. Specify the quantity, directions for use, and refills.
4. Proceed to Section C, where the provider must declare and authorize the information provided. Ensure the provider signs and dates the section to confirm the accuracy and completeness of the application.
5. In Section D, the patient must fill out their information, including name, address, phone, and drug allergies, if any.
6. Complete Section E regarding coverage and insurance. Indicate if the patient has Medicaid or any other insurance and provide explanations if necessary.
7. In Section F, the patient must provide financial information. State the current annual household income and indicate the number of household members dependent on that income. Choose either to enclose documentation or to have a healthcare provider certify the income.
8. Finally, review Section G for the applicant's declaration and authorization. The patient must sign and date this section, certifying the accuracy of the information.
9. Once all sections are filled, save your changes. You can download, print, or share the completed form as needed.

Complete the Arch Patient Assistance Program Income Limits form online today to access the assistance you need.