Get Takeda Help At Hand Application 2023-2025

This guide provides detailed instructions on completing the Takeda Help At Hand Application online. By following these steps, you can ensure that your application is filled out accurately and submitted efficiently to receive support for your medications.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to access the Takeda Help At Hand Application. This will open the form for you to start filling it out.
2. Begin with Section 1: Patient Information. Enter the patient's last name, first name, home address, city, state, cell phone number, zip code, and email address. Ensure that you provide clear and accurate information.
3. In Section 1, you will also check the box to authorize Takeda to send text messages related to your application status. Select 'Yes' or 'No' as per your preference, and provide the patient's date of birth (DOB) and gender.
4. Move to Section 2: Insurance and Income. Indicate whether the patient has prescription drug insurance by checking all applicable options. Additionally, provide the total yearly household income and any necessary documentation, such as tax returns or income statements.
5. Answer questions about recent job loss and financial hardship in Section 2. If applicable, attach proof of job termination or unemployment.
6. Proceed to Section 3: Prescriber Information. Fill in the prescriber’s first name, last name, address, phone number, fax number, state, zip code, NPI number, and state license number.
7. Complete Section 4: Prescription Information by selecting the prescription product needed, specifying the strength, directions, quantity, and refills required. Ensure accuracy in the product selection.
8. In Section 5: Patient Declarations, read the statements carefully and sign to confirm the information is accurate. Ensure that you clearly print the date of signing.
9. Finally, review the last section, Section 6: Patient Authorization. Sign and date this section, and if applicable, provide the name and relationship of the legal representative.
10. Once all sections are completed, save your changes. You can then download the application for your records, print it, or share it as needed. Ensure that all attachments mentioned are included.

Start your application online today to access the support you need.