Follow the steps to successfully complete your application checklist.

1. Click ‘Get Form’ button to access the application and open it in your preferred online editor.
2. Begin by filling out Section 1: Applicant Information. Ensure you provide your full name, mailing address, date of birth, social security number, and income details. Indicate any known drug allergies and health conditions.
3. Continue to Section 2: Prescription Coverage. Answer the questions regarding your prescription drug coverage and eligibility for various programs, including Medicare Part D. Provide any necessary documentation if you are a Medicare Part D applicant.
4. In Section 3: Authorized Individuals, list any individuals you authorize to act on your behalf. Include their contact information and relationship to you.
5. If applying as a vaccine patient, proceed to Section 4: Shipping Address. Fill in the prescriber's registration details and preferred delivery information.
6. Next, fill out Section 5: Prescriber Information and Certification. Have the prescriber sign the section to certify the need for the requested medication.
7. For non-vaccine applicants, complete Section 6: Advocate Information if applicable. If you have an advocate, include their details and ensure they sign the certification.
8. If the shipping address differs from your mailing address, complete Section 7: Shipping Address with all required details.
9. Finally, sign Section 8: Patient Certification to authorize GSK to process your application and certify the accuracy of your information.
10. Review the entire application for accuracy. Save any changes, and download or print the form for your records before submission.

Complete your application checklist online today to ensure timely access to the medications you need.