Get Bmspaf Application Form 2021-2025

The Bristol Myers Squibb Patient Assistance Foundation (BMSPAF) Application Form is designed to help eligible patients access essential medications at no cost. This guide provides a clear, step-by-step process to assist you in completing the form online accurately and efficiently.

Follow the steps to complete the BMSPAF Application Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete Section I for patient information, which includes filling in your name, social security number (optional), date of birth, gender, and contact details. Ensure all fields are filled out as required.
3. Provide your insurance information by checking the applicable boxes for your insurance providers. Include details of your insurance coverage, if applicable.
4. Indicate the number of people in your household and disclose your total yearly or monthly household income. Attach proof of income documentation as necessary.
5. List any allergies and current medications. If additional space is needed, attach a separate page.
6. Proceed to the Patient Agreement & Consent section, read it thoroughly, and sign and date the agreement to apply.
7. Section II requires completion by the prescriber. The prescriber should fill in the patient's name, date of birth, treatment details, and prescription information.
8. In Section III, the prescriber must provide their information, including their license number and office details.
9. Complete Section IV regarding the shipping address for medication. Ensure that you cannot use a PO Box.
10. The prescriber must sign and date the application to certify that the provided information is accurate.
11. After completing the form, review all entries for accuracy. Save changes, download the form, and share it as required.

Take the first step towards accessing assistance by filling out your BMSPAF Application Form online today.