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Get Valeant Patient Assistance Program Application 2012-2024

D and signed (no signature stamps) The practitioner must complete the Prescription Information section, or include an original prescription written for a 6 month supply of the name brand medication** requires Rx attached Attach a copy of the patient s most recent Federal tax return o If the patient does not file a Federal tax return, please attach other proof of annual household income (i.e. W-2, 1099, social security, disability or pension statement, unemployment award letter, etc. fo.

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