Get Sunovion Support Prescription Assistance Program Application 2014-2025

This guide provides clear and professional instructions on how to complete the Sunovion Support Prescription Assistance Program Application online. By following these steps, users can efficiently provide the necessary information to receive assistance for their APTIOM prescription.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to obtain the application form and open it for editing.
2. Fill in the patient information section, which includes the patient's name, date of birth, phone number, gender, and mailing address. Be sure to provide the full and accurate address including city, state, and zip code.
3. Indicate whether the patient is a US resident by selecting 'Yes' or 'No'.
4. Complete the household income information by providing the number of people in the household and the total gross annual income. Include all sources of income such as wages, Social Security, and disability payments.
5. Specify whether the patient filed a Federal Income Tax Return for the previous calendar year. If applicable, provide documentation to verify gross annual income.
6. Fill out the patient's insurance information. Indicate whether the patient is enrolled in Medicare and if they have any additional prescription coverage.
7. Ensure that both the patient and healthcare professional sign the application. Include the necessary signatures at the designated areas, verifying the accuracy of the information provided.
8. After completing the form, review all sections for accuracy. Print or save a copy of the filled application for your records.
9. Submit the application by mailing it to the provided address or by faxing it to the appropriate number listed in the instructions.

Take the first step to securing your prescription assistance by completing the Sunovion Support Prescription Assistance Program Application online today.