Follow the steps to complete the application form successfully.

1. Click the ‘Get Form’ button to access the BMSPAF Application Form and open it for editing.
2. Begin with Section I: Patient Information. Fill in all required fields, including your full name, date of birth, contact information, and any known allergies. If you have no allergies, write 'none'. Ensure all fields are completed to avoid delays.
3. Provide your insurance information, indicating all applicable insurance types. If you do not have insurance, select 'None'. Attach a copy of your prescription insurance card if applicable.
4. Indicate the number of people living in your household and clearly state your total yearly or monthly household income. You may need to provide proof of income documents as specified.
5. Complete the Patient Agreement & Consent by reading it carefully. You must sign and date this section to confirm your agreement with the terms.
6. Move to Section II for the licensed prescriber. Fill in the necessary information regarding treatment and prescriptions prescribed. Ensure the prescriber signs and dates this section.
7. In Section III, provide the prescriber’s details, including their name, license number, and contact information.
8. For Section IV, specify where the medication should be shipped. Indicate the shipping address and confirm that it is not a PO Box.
9. Review your application for completeness, ensuring every section is filled out entirely. Missing information may delay your application.
10. Once all sections are complete, save your changes. You can then download, print, or share the form as needed, before submitting it either by mail or fax.

Complete your BMSPAF Application Form online today to receive assistance with your medication needs.