Get Patient Savings Program Application

Filling out the Patient Savings Program Application online is a straightforward process designed to assist individuals seeking financial support for their treatment. This guide will provide you with clear instructions to complete the application efficiently.

Follow the steps to complete your application online.

1. Press the ‘Get Form’ button to access the Patient Savings Program Application form and open it in your preferred editor.
2. In Section 1, provide your patient information. Ensure to fill out all fields marked with an asterisk and attach an enlarged copy of the front and back of your insurance card and/or other relevant insurance information.
3. Complete the fields for your personal details, including your last name, first name, date of birth, gender, address, and contact numbers. Make sure your email address is typed accurately for any future communications.
4. Fill out your primary and secondary insurance information, including the names of the insurance providers, phone numbers, group numbers, and ID numbers. Complete the prescription insurance phone number field if applicable.
5. Respond to the eligibility questions regarding your past treatments, insurance status, and residency. Each question requires a yes or no answer, so read them carefully before making your selection.
6. In Section 2, provide the healthcare provider's information. Include your physician's name, practice name, contact details, and the practice's address to complete this section.
7. Review Section 3 for signatures. The patient must sign to authorize enrollment and understand the disclosure of personal health information. Be sure to include your printed name and the date alongside your signature.
8. Once all sections are completed, double-check for accuracy and completeness before submitting the application. You can then save your changes, download the completed form, print it, or share it as necessary.

Begin your application process online to access support for your treatment.