Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the application and open it in the editor.
2. Begin by indicating if this is a New Application or Re-Enrollment. Select the appropriate option and ensure all required fields marked with an asterisk are filled in.
3. Enter the patient's first and last name, street address, city, state, zip code, phone number, and email address, ensuring clarity and legibility.
4. Provide the patient's date of birth and the prescriber’s details, including their first and last name, phone number, and any related prescription drug coverage information. Make sure to check 'Yes' or 'No' regarding prescription drug coverage.
5. If applicable, complete Section B regarding Medicare Prescription Drug Coverage consent. Ensure to sign and date where necessary.
6. Securely check and sign in Section C for Income Verification Consent, and make sure to provide accurate financial details.
7. For Section D, consent to the Collection of Health Information for program participation, which requires both a checkbox confirmation and a signature.
8. Before moving to Section E, read and acknowledge the HIPAA Authorization, again ensuring both checkbox and signature requirements are met.
9. Complete details in Section F about any authorized representatives you wish to appoint who may communicate on your behalf with the program.
10. In Section G, give consent for contact regarding program participation via phone or messages.
11. Fill in Section H for any safety information, permitting Novo Nordisk to share necessary personal information in the event of a concern.
12. In Section I, certify your eligibility by signing and dating, ensuring all conditions outlined in the application are understood and accepted.
13. Review the entire application for completeness and accuracy, ensuring all required fields are filled and all necessary documents are attached.
14. Finally, submit your application by saving any changes, and consider downloading or printing a copy for your records.

Start completing your Novo Nordisk Patient Assistance Program Application online today to gain access to necessary medications.