Get (oncology) Application - Bms Patient Assistance Foundation

Filling out the BMS Patient Assistance Foundation Oncology Application online is a straightforward process that helps ensure patients have access to necessary medications. This guide provides step-by-step instructions to assist you in accurately completing the application.

Follow the steps to effectively complete the application online.

1. Press the ‘Get Form’ button to access the Oncology Application. This will allow you to download and open the form in an appropriate editor.
2. Begin with the Patient Information section. Provide your first name, middle initial, and last name, followed by your date of birth. Enter your residential address, including the street, city, state, and zip code, and fill out your mailing address if it differs from your residential address.
3. Fill in your social security number and provide a phone number for contact. Specify your gender and ensure all fields are accurately completed.
4. In the Patient Eligibility Information section, attach proof of annual household income. This documentation can include your federal tax form or other relevant income sources.
5. Indicate your household size and confirm whether you have any public or private prescription drug coverage by selecting 'Yes' or 'No.'
6. In the Healthcare Provider Information section, the prescribing practitioner must complete their name, professional designation, and state license number.
7. Provide the name of the facility, along with the shipping address, contact name, and phone number.
8. List the requested medication by including the drug name, dosage, frequency, and planned treatment dates if applicable. Indicate if this is a change in dose schedule for an existing patient.
9. Ensure both the patient and healthcare provider sign the application where indicated and input the date. This is crucial for processing your application.
10. After completing the application, you can submit it by mail or fax. If mailing, send the application to the provided address. If using fax, ensure you do not send multiple copies.
11. Once submitted, you can save any changes to the document and download, print, or share the form as needed.

Begin filling out the BMS Oncology Application online today to ensure timely patient assistance.