Get Valeant Patient Assistance Program Application - Bausch + Lomb

The VALEANT Patient Assistance Program provides essential support for individuals in need of access to medication. This guide offers step-by-step instructions on how to efficiently complete the online application form to ensure you receive the assistance you need.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the Patient Information and Insurance Information sections located on page 1. Ensure that all fields marked with an asterisk (*) are filled in clearly and accurately. If a question does not apply to you, write 'N/A'.
3. Read the Patient Authorization and Certification on page 2. After you understand the terms, sign and date the document to confirm your consent.
4. Have your prescriber complete pages 3 and 4. They must enter their information, select the appropriate product, and sign the Prescriber Certification on page 4.
5. If you have medical or prescription insurance, attach copies of your insurance cards as instructed.
6. Once the application form is completed, submit it along with any requested documentation by mailing or faxing it to the provided address: VALEANT PATIENT ASSISTANCE PROGRAM, P.O. BOX 429303, Cincinnati, OH 45242-9303.
7. You can also save the changes, download, and print the completed application for your records, or share it if necessary.

Access the online application today and take the first step toward receiving the assistance you deserve.