Get Takeda Help At Hand Application 2017

Filling out the Takeda Help At Hand Application online is a straightforward process designed to assist users in obtaining access to necessary medications. This guide will walk you through each step of the application, ensuring that you complete it efficiently and accurately.

Follow the steps to successfully complete your application.

1. To begin, select the ‘Get Form’ button to access the Takeda Help At Hand Application. This will allow you to open the form in the designated online format.
2. Carefully read through the eligibility criteria for the program to confirm that you qualify before proceeding with the form. Ensure you meet all necessary requirements, including residency status and income guidelines.
3. In Section 1, provide your personal information, including your name, address, contact number, and date of birth. Make sure to print clearly in black or blue ink if filling out a physical form.
4. Move to Section 2, where you will fill out your healthcare provider's information, including their name, address, and contact details. You will also need to indicate any allergies to medications. Ensure this section is complete and accurate as it will require your healthcare provider's signature.
5. In Section 3, include the details of your prescription, specifying the Takeda product, directions for use, supply days, and the number of refills. This section also requires the healthcare provider's signature certifying the necessity of the prescribed therapy.
6. Proceed to Section 4 by providing details about your insurance and income. Indicate any existing health coverage and submit required documentation to prove your current income status as outlined in the section.
7. If applicable, complete Section 5 regarding Medicare Part D eligibility. Read the statements carefully and sign to acknowledge your understanding and agreement to the terms.
8. Finally, complete Section 6, which involves authorizing the release of your healthcare information to Takeda. Review the statement thoroughly and provide your signature before submission.
9. After filling out all sections, ensure all required documents are attached. You can then submit your application by faxing or mailing it to the address provided.
10. Once submitted, you can save the form for your records, download a copy for personal use, or print a hard copy. Await a response from the Takeda Patient Assistance Program, which will update you within five to seven business days.

Start your application process online today to access the medications you need.