Get Bristol Myers Squibb Patient Assistance Form

Completing the Bristol Myers Squibb Patient Assistance Form online can help you access vital medications at no cost. This guide will walk you through each component of the form to ensure a smooth and efficient application process.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the Bristol Myers Squibb Patient Assistance Form and open it in your document editor.
2. Begin with Section I: Patient Information. Complete all required fields, including your name, social security number, and address. Note that providing your SSN is optional.
3. In the Patient Information section, provide your contact numbers, best time to call, and list any allergies and current medications. You may attach additional lists if needed.
4. Next, provide details about your insurance coverage. Indicate if you have Medicaid, Medicare, VA benefits, or private insurance, and include corresponding policy numbers.
5. Specify the number of individuals living in your home and your total yearly or monthly household income. If necessary, indicate any documentation you will attach as proof of income.
6. Proceed to sign and date the Patient Agreement and Consent section, confirming the accuracy of the information provided.
7. If applicable, Section II must be completed by your healthcare provider including treatment and prescribing information, along with necessary prescriptions.
8. In Section III, the provider must include their details including name, facility, and address for shipping the medications.
9. Once all sections are completed, review to ensure all information is accurate. Save your changes, then download, print, or share the form as required.

Begin your application process today by filling out the Bristol Myers Squibb Patient Assistance Form online!