Get Amgen Safety Net Foundation Patient Application 2021-2025

The Amgen Safety Net Foundation provides vital assistance to qualifying individuals seeking access to Amgen medicines at no cost. This guide will walk you through the necessary steps to complete the patient application online with clarity and confidence.

Follow the steps to effectively fill out the application.

1. Press the 'Get Form' button to access the application and open it in your document manager.
2. Review the requirements for eligibility before filling out the form. Ensure that you have lived in the eligible areas for at least six months and verify your household income falls within the specified limits.
3. Provide essential personal information in the 'Patient Information' section, including your name, date of birth, address, and contact numbers. Be certain to select your preferred language and acknowledge your communication consent.
4. In the next section, specify details about your insurance status. If you have health coverage, detail the specifics of your primary insurance, including plan name and member ID. Provide accurate responses about your eligibility for Medicaid or Medicare options.
5. Complete the 'Prescriptions' field with information about the medicines prescribed to you. Ensure that you clearly demonstrate the prescribed medications and their dosages.
6. After filling in all necessary fields, have your physician review and complete any sections required from them, including their signature and relevant medical details.
7. Once all sections of the application are finalized, you may submit the completed form by faxing it together with the necessary prescription to the designated number.
8. After submission, do not forget to save a copy of your application. You can either download, print, or share the finalized document for your records.

Begin your application online today to access the support you need.