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Get Lilly Cares Refill Form 2020-2026
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How to fill out the Lilly Cares Refill Form online
The Lilly Cares Refill Form is an essential document for patients seeking assistance with their medication refills. This guide will provide step-by-step instructions to ensure that you fill out the form accurately and efficiently.
Follow the steps to complete the Lilly Cares Refill Form.
- Press the ‘Get Form’ button to obtain the Lilly Cares Refill Form and open it in your preferred editor.
- Begin by filling in the patient’s personal details. Enter the patient’s name, address, date of birth, and the current date in the designated fields.
- Indicate the patient's continued eligibility by checking the appropriate box or note as required. Specify the desired duration of the medication supply, using ‘4-month supply’ as indicated.
- Fill in the product details including the name of the product being requested, the signature instructions (Sig), dosage, and quantity needed.
- Provide complete shipping information. This includes the prescriber’s name, office or clinic name, street address, city, state, and zip code. Note that PO boxes or third-party vendors cannot be used.
- In the Healthcare Provider’s Attestations and Agreement section, read carefully through the terms outlined. Ensure you understand the requirements and confirm your agreement by signing and printing your name as the prescriber.
- Complete all additional required fields, including the healthcare provider's phone and fax numbers, and indicate your medical qualification by circling the appropriate title.
- Finally, review the entire form for accuracy, save any changes, and if necessary, download, print, or share the filled-out form as required.
Take the next step toward managing your medication by completing the Lilly Cares Refill Form online today.
To get refills from Lilly Cares, you should fill out the Lilly Cares Refill Form. This form is essential for ensuring that your medication needs are met efficiently. After completing the form, submit it through the designated channels, either online or by mail. Lilly Cares will review your request and keep you informed about your refill status.
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