Get Kaleo Cares Patient Assistance Program

Filling out the Kaleo Cares Patient Assistance Program form can help individuals experiencing financial difficulties access necessary medications. This guide provides clear instructions to assist users in completing the form accurately and efficiently.

Follow the steps to fill out the Kaleo Cares Patient Assistance Program form online.

1. Click ‘Get Form’ button to obtain the Kaleo Cares Patient Assistance Program document and open it in your preferred online editing tool.
2. Provide the patient information, including the patient’s full name, social security number, date of birth, weight, and address. Be sure the address is not a P.O. Box.
3. Select the gender of the patient by checking either 'Male' or 'Female'. Input the city, state, and zip code as required.
4. Fill in the patient's contact information, including cell phone, home phone, and email address.
5. If the patient is a minor, enter the name of the parent, caregiver, or guardian.
6. Indicate whether the patient has prescription drug coverage and whether they have commercial insurance.
7. Check any applicable programs for which the patient may be eligible, such as Medicaid, Medicare, or Tricare.
8. Provide the annual household income and the number of dependents. Note that proof of income may be required.
9. Read and sign the affirmation to acknowledge understanding of the program's terms and conditions.
10. Complete the prescriber and prescription information section with the prescriber’s details, including name, NPI, specialty, and contact information.
11. Input the prescription details for AUVI-Q, including the prescribed dosage and any relevant diagnosis code.
12. The prescriber must sign and date the form, certifying that the provided information is accurate.
13. Fax the completed form to (800) 943-1730 as instructed.
14. For any questions during the process, call 502-213-7601 for assistance.

Complete your Kaleo Cares Patient Assistance Program document online today.