Follow the steps to complete your application smoothly.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred digital editor.
2. Begin filling out Section 1: Patient Information. Provide your first and last name, address, city, state, zip code, preferred daytime phone number, date of birth, gender, last four digits of your Social Security Number (SSN), and preferred language.
3. Complete Section 2: Patient Financial Information. Indicate how many people live in your household and state your total household income for the year. Also, report total household assets, excluding your primary home or car.
4. Fill out Section 3: Insurance Information. Answer the questions concerning any disability payments, Medicare, Medicaid, or insurance coverage you may have. Ensure to circle your responses.
5. Proceed to Section 4: Patient Attestation & HIPAA Authorization. Review the statements to ensure they are accurate, and then sign and date the section.
6. In Section 5: Prescriber Information, have your healthcare provider fill out their information, including their name, specialty, and contact information. Ensure they sign the section as well.
7. Complete Section 6: Prescription & Medication Information. Your prescriber should provide details regarding the medication prescribed, including the product name, dosage, directions, and any existing medication allergies.
8. After carefully reviewing all entered information for accuracy, save the completed application. You may then download the document, print it for physical submission, or share it as necessary.

Complete your application online today to gain access to the support you need.