Get Xelsource Forms

This guide provides a step-by-step approach to filling out the Xelsource Forms online, ensuring that users can complete the application efficiently and accurately. It is designed to be user-friendly for individuals with varying levels of experience.

Follow the steps to complete the Xelsource Forms.

1. Click 'Get Form' button to obtain the form and open it in the editor. This step allows you to access the Xelsource Forms required for the application.
2. Enter the patient information, including the patient's full name, address, city, state, ZIP code, phone numbers for day and evening, and email address. Providing an email can expedite the application process.
3. Fill in the date of birth (DOB) accurately to confirm the age of the patient applying for assistance.
4. Select whether the patient has prescription drug coverage. If not, confirm by checking the appropriate box.
5. Provide information about the total number of people in the household and the total annual household income, ensuring to include documentation supporting this financial information.
6. Under the financial information section, attach required documents such as the most recent federal tax return, W-2 forms, or any other financial proofs as instructed.
7. Read the patient declaration carefully and sign to affirm that the answers and documents provided are accurate to the best of your knowledge. If the applicant is under 18 years of age, a parent or guardian must sign.
8. Review all entered information for accuracy before saving the form. Once verified, you can save changes, download, print, or share the completed form as needed.

Complete your Xelsource Forms online now to access patient assistance.