Get Takeda Patient Assistance Program

This guide provides detailed instructions to assist users in completing the Takeda Patient Assistance Program application online. By following these steps, individuals can ensure their information is accurately submitted for assistance.

Follow the steps to complete the Takeda Patient Assistance Program application.

1. Click ‘Get Form’ button to access the Takeda Patient Assistance Program application form which you will fill out online.
2. Begin with Section 1, patient information. Fill in your first and last name, home address, city, state, ZIP code, preferred daytime phone number, date of birth, and confirm U.S. residency.
3. Proceed to Section 2, healthcare provider information. Enter your healthcare provider's first and last name, clinic name, full address, state license number, phone number, and fax number. Include any current medications and indicate if you have any medication allergies.
4. Continue to Section 3, prescription information. Here, list the Takeda product name and strength, provide directions for use, the days supply, and select the number of refills needed.
5. In Section 4, insurance and income, indicate your prescription drug insurance status, household size, and total yearly household income. Attach the necessary proof of income documentation as outlined.
6. Complete Section 5, patient declarations. Carefully read the statements, sign, and date the form to confirm all information is accurate and that you agree to the terms.
7. Fill out Section 6, patient authorization. Review the authorization statement regarding the sharing of protected health information, sign, and date it.
8. Once all sections are complete, review your information for accuracy. Save your changes and then download, print, or share the completed form as instructed. Finally, fax or mail the application and all required documentation to the Takeda address provided.

Complete your application online for the Takeda Patient Assistance Program today.