Get Patient Assistance Form

Filling out the Patient Assistance Form is a vital step in accessing no-cost medications for eligible users facing financial hardships. This guide will help you navigate through the form's sections with clear, step-by-step instructions.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to access the Patient Assistance Form and open it for editing.
2. Begin with Section 1: Prescriber Information, where the prescriber must provide their details including name, office name, address, and contact information.
3. Proceed to Section 2: Patient History. Fill in the patient's name, date of birth, allergies, and any current medications, if applicable.
4. Move on to Section 3: Prescription. The licensed prescriber needs to indicate the prescription details, choosing the necessary dosage of ® and additional instructions.
5. Complete Section 4: Prescriber Certification and Signature. The prescriber must manually sign and date this section to validate the form.
6. If you are a patient, start Section 5: Patient Information. Fill in your name, date of birth, last four digits of your Social Security Number, mailing and shipping address, and preferred contact phone number.
7. In Section 6: Financial Information, provide total household income and attach proof of income, ideally a current federal tax return.
8. Under Section 7: Insurance Information, specify whether you have insurance and include a copy of your prescription insurance card. List relevant prescriptions for consideration.
9. Go to Section 8: Patient Consent and Signature. Review the privacy notice and terms before providing your signature and date after confirming your understanding.
10. If desired, fill out Section 9: Additional Permission for Program Purposes, indicating any person with whom you authorize the foundation to discuss your application.
11. Finally, review Section 10: Patient Privacy Notice and Terms of Participation. Take note of the information provided and ensure all sections are completed accurately.
12. Once the form is fully completed, save your changes, and you can download, print, or share the document as required.

Complete your Patient Assistance Form online today to access the support you need.