Get Allergan (actavis) Medication Assistance Ecu Physicians

This guide provides a step-by-step approach to accurately completing the Allergan (Actavis) Medication Assistance form online. By following these instructions, applicants will be empowered to navigate the submission process smoothly.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred online editor.
2. Begin with Section 1.0, where you will need to provide details of your licensed prescriber. Fill in their first name, last name, state license number, professional designation, DEA number, and mailing address including city, state, and zip code. Ensure to include the delivery address as well.
3. Proceed to Section 2.0 to fill in your personal information. Enter your legal first name, last name, phone number, gender, date of birth, and mailing address. Additionally, clarify your marital status and whether you are a veteran or have received disability payments.
4. Move to Section 2.1 and provide income details. Include all sources of income such as salary, Social Security, alimony/child support, disability, and so forth. Calculate and enter your total gross monthly income.
5. Next, in Section 2.2, provide other coverage information. Indicate if you have any VA or military benefits, Medicare or Medicaid enrollment, along with details of any private prescription coverage.
6. In Section 3.0, sign and date the patient certification to confirm that you cannot afford the requested medication and that the information provided is correct. This signature is valid for 12 months.
7. Lastly, the licensed prescriber must complete Section 4.0, sign it, and provide the necessary prescription for the medication. Once all sections are complete, review the application for accuracy.
8. After thorough verification, save your changes. You can then download, print, or submit the form directly to the relevant party.

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