Follow the steps to accurately complete your application.

1. Click the ‘Get Form’ button to obtain the Boehringer Ingelheim Cares Foundation Patient Assistance Program Application form and open it for editing.
2. Complete Section 1, which includes providing your personal information: first name, last name, address, city, state, zip code, and preferred daytime phone number. Include your date of birth, gender selection, last four digits of your social security number, and preferred language.
3. In Section 2, input your financial information. Indicate the number of people living in your household and the total annual household income. Provide total household assets, excluding your first home and car. Ensure you understand the consequences of providing accurate financial information, as verification may be required.
4. Section 3 requires you to provide information regarding your insurance status by selecting 'Yes' or 'No' for various questions related to disability payments, Medicare, Medicaid, and other coverage scenarios.
5. In Section 4, you must attest to the information provided and authorize the use of your health information. Read the statements carefully and sign to confirm your understanding and agreement of the conditions outlined.
6. Complete Section 5 for the prescriber information. The healthcare provider should fill out their name, specialty, contact information, and any necessary details regarding the patient’s prescription.
7. Finally, provide medication information in Section 6, including the product name, strength, directions, any medication allergies, and details about current medications. Signature from the prescriber is also required in this section.
8. After completing all sections, review the application for accuracy. Once satisfied, save your changes, print, or download the form to submit it via mail or fax as instructed.

Start filling out your application online today to receive the support you need.