Get Otsuka Patient Assistance Program

The Otsuka Patient Assistance Program provides essential medications at no cost for eligible patients. This guide will help you navigate the online application process, ensuring you can complete the form accurately and effectively.

Follow the steps to complete your application form.

1. Click the 'Get Form' button to obtain the application form and open it in the appropriate editor.
2. Begin with Section 1, the patient authorization. Carefully read the content and then provide your signature, indicating your consent for the use of your protected health information.
3. Proceed to Section 2, where you need to fill out your demographic information, including your first name, last name, date of birth, and contact details. Ensure all required fields are completed.
4. In Section 3, provide your insurance information. Ensure you attach copies of your insurance and prescription cards, if applicable.
5. Move on to Section 4 to answer questions regarding your insurance eligibility. Provide clear and accurate answers to each question to facilitate processing.
6. In Section 5, complete the financial eligibility information. Specify your annual household income and the number of people living in your household.
7. Next, sections 6 and 7 must be completed by your healthcare provider. Ensure they fill out the prescriber information and prescription details accurately.
8. Once all sections have been completed, review the application for accuracy. Make any necessary corrections before saving your changes.
9. Finally, submit the completed form by faxing to 1-844-727-6274 or mailing it to the Otsuka Patient Assistance Foundation, PO Box 3640, Gaithersburg, MD 20885-3640.

Start filling out your Otsuka Patient Assistance Program application form online today!