Get Donnatal Patient Assistance Form

Filling out the Donnatal Patient Assistance Form online can seem overwhelming at first, but this guide will provide clear instructions to help you navigate the process with ease. This form is designed to assist individuals who require financial aid to obtain their medications.

Follow the steps to accurately complete the form online.

1. Click the ‘Get Form’ button to access the Donnatal Patient Assistance Form and open it in your preferred editor.
2. Begin by entering your personal information in the Applicant Information section. Provide your full name, date of birth, phone number, current address, city, state, and ZIP code.
3. Next, indicate where you heard about the Patient Assistance Program. This will help the organization track outreach efforts.
4. If you are not on Medicare or Medicaid, you will need to complete the Income Information section. Here, list your current annual household income and check all applicable income sources such as Social Security benefits, wages, interest/dividends, pension, unemployment, or any other sources.
5. Proceed to the Insurance/Coverage Information section. Indicate whether you have prescription coverage by selecting 'Yes' or 'No.' If 'Yes,' check all applicable coverage options, including Medicare, Medicaid, State Pharmacy, and Employer coverage. If there are other options, please list them.
6. In the Physician/Healthcare Provider Information section, provide the name, phone number, and fax number of your healthcare provider, as well as the address including city, state, and ZIP code. You will also need to indicate the preferred product by circling either Elixir or Tablets.
7. Read the disclaimer carefully. By signing the form, you acknowledge that submitting the information is an application for consideration in enrolling in the program, and acceptance is not guaranteed.
8. Finally, sign and date the form to confirm the accuracy of the information provided. After completing all sections, you can save changes, download, print, or share the form as needed.

Complete your Donnatal Patient Assistance Form online today to take the next step towards receiving the support you need.