Get Kalo Cares Patient Assistance Program

The KALO CARES Patient Assistance Program is designed to provide support to individuals facing financial difficulties in obtaining necessary medications. This guide will walk you through the online process of filling out the application form step-by-step, ensuring clarity and ease throughout.

Follow the steps to complete the application online.

1. Press the 'Get Form' button to access the KALO CARES Patient Assistance Program application form and open it for editing.
2. Begin with Section 1: Patient Information. Fill in your first name, last name, street address (PO Box is not acceptable), city, state, zip code, and primary phone number. Indicate if you are a US resident by checking 'Yes' or 'No', and select your gender accordingly.
3. Provide your secondary phone number and enter your Social Security Number or Green Card/Visa number along with your date of birth in this section.
4. Move to Section 2: Insurance and Income Attestation. Indicate whether you have prescription drug coverage by checking 'Yes' or 'No'. Then, specify if you have commercial insurance or are eligible for government insurance, such as Medicare, Medicaid, or Tricare.
5. Enter the total number of people in your household and the number of dependents. Then, provide your annual household income. Note that proof of income may be required later.
6. In the declaration section, affirm that the information provided is accurate and grant consent for KALO CARES to share your enrollment information as necessary. Include your signature and date.
7. Proceed to Section 3: Patient Privacy and Consent. Here, read the terms regarding the use of your information, and provide your signature and date to consent to the stated terms.
8. Continue to Section 4: Healthcare Provider Information. Complete the prescriber’s first and last name, street address, city, state, zip, office contact name, office phone, office fax, state license, NPI, and DEA.
9. In Section 5: Prescription, choose the appropriate AUVI-Q® dosage, fill in directions, quantity, diagnosis, ICD-10 code, and anticipated start date. The prescriber must sign and confirm that the prescribed medication is medically appropriate.
10. After completing the form, review all the entered information for accuracy. You may then save your changes, download or print the completed form, and submit it via fax as instructed.

Begin completing your KALO CARES Patient Assistance Program application online today.