Follow the steps to successfully complete the application form.

1. Press the ‘Get Form’ button to access the application and open it for editing.
2. Fill out the patient information section, which requires the patient's name, date of birth, phone number, gender, mailing address, city, state, and zip code. Confirm whether the patient is a U.S. resident and if they are 18 years of age or older.
3. If the patient is under 18 or has a court-appointed legal guardian, complete the legal guardian information section with their name, phone number, mailing address, city, state, and zip.
4. Provide household income details, including the number of people in the household and the total gross annual income. Indicate whether the parent/legal guardian filed a Federal Income Tax Return for the previous calendar year and attach the necessary proofs of income.
5. Complete the patient’s insurance information, indicating if the patient is enrolled in Medicare/Medicaid and whether they have other prescription drug coverage.
6. The health care professional must complete their section of the application, including their name, state license number, facility name, contact information, and the prescription details for Aptiom®.
7. Review and select the appropriate ICD-10 code from the provided list that corresponds to the patient’s diagnosis.
8. Provide the required consents and signatures from both the patient and health care professional, ensuring that all necessary agreements regarding the accuracy of the information and consent to share health information are completed.
9. After filling out the application, ensure that all required documents are attached. You can save the changes, download the completed form, print it, or share it as needed.

Complete your application online today to access the Sunovion Support Prescription Assistance Program.