Get Novartis Patient Assistance Foundation Enrollment Application 2018-2025

Filling out the Novartis Patient Assistance Foundation Enrollment Application online is a vital step for users seeking assistance with their medications. This guide will provide detailed instructions on each section of the form to ensure a smooth enrollment process.

Follow the steps to fill out the application correctly.

1. Press the ‘Get Form’ button to access the Enrollment Application for the Novartis Patient Assistance Foundation, Inc. and open it in your viewing application.
2. Complete the Patient Section A by entering your personal information, including your name, address, contact number, email, and confirming your residency in the U.S. Additionally, indicate whether you identify as disabled, are a veteran, and provide your date of birth.
3. In the financial documentation section, choose to either consent to electronic income verification by checking the appropriate box or attach copies of relevant financial documentation such as tax returns or pay stubs.
4. List your household information, including the total number of people living in your home and your gross monthly income from various sources like salary, pensions, or social security.
5. Provide necessary information regarding your insurance coverage. This includes uploading a copy of the front and back of your insurance card and indicating your coverage status for Medicare, Medicaid, and other assistance programs.
6. Review and sign the Patient Consent section to allow for the necessary information sharing with healthcare providers and Novartis. Ensure that you print your name, sign, and date the form.
7. Complete the Health Care Professional Section A by having your HCP fill out their personal information, including name, address, phone number, and required prescriptions.
8. Once all fields and sections are complete, review the application for accuracy, make any necessary changes, and save the completed document. You may then download, print, or share the form as needed.

Complete your application online today to access the assistance you need!