Get Allergan Patient Assistance Program Application

The Allergan Patient Assistance Program offers eligible individuals access to Allergan medications at no cost. This guide provides step-by-step instructions for completing the application form online, ensuring that users understand each section and field required for submission.

Follow the steps to successfully complete the application form.

1. Press the ‘Get Form’ button to obtain the Allergan Patient Assistance Program application form and open it in your preferred document editor.
2. Begin by completing Section 1, which requires prescriber information. This includes the prescriber’s name, NPI, designation, state license, DEA, office name, and contact information.
3. Proceed to Section 2 to fill out the patient information, including the patient’s first and last name, date of birth, gender, phone number, and shipping address.
4. In Section 3, provide detailed medication information as requested. This must include the product name, strength, quantity, directions, and refills required, which must be completed by a licensed prescriber.
5. Move to Section 4 where the prescriber must manually sign and date the form to verify that all information is accurate and complete.
6. If you are the patient, complete Section 5 by providing your first name, last name, date of birth, and mailing address again.
7. In Section 6, provide your financial information. Include the total monthly income for all household members and attach required financial documentation, preferably your current tax return.
8. Move on to Section 7 for insurance information. Indicate whether you have insurance and provide a detailed list of medical and prescription drug costs.
9. Complete Section 8 by reviewing the patient consent statement. Sign to acknowledge understanding and agreement to the terms, including the HIPAA authorization.
10. If applicable, utilize Section 9 to grant additional permissions for the program's purposes by entering the name and relationship of the person you authorize.
11. After ensuring all sections are complete and all required documents are included, save your changes. You may download, print, or share the completed application as needed.

Complete the application form online to access your Allergan medication assistance today.