Get the free Bristol-Myers Squibb Patient Assistance Program Application

This application form is for patients seeking assistance from the Bristol-Myers Squibb Patient Assistance Foundation's Oncology Patient Assistance Program. It includes sections for patient information,

How to fill out bristol-myers squibb patient assistance

How to fill out Bristol-Myers Squibb Patient Assistance Program Application

1. Download the Bristol-Myers Squibb Patient Assistance Program Application from their official website.
2. Carefully read the instructions provided on the first page of the application.
3. Fill out the patient information section with your full name, address, date of birth, and contact information.
4. Complete the insurance information section, providing details of any existing insurance coverage.
5. If you do not have insurance, indicate that in the application as per the guidelines.
6. Fill out the income information section to demonstrate financial need, including household income and size.
7. Gather supporting documents such as proof of income, bank statements, and tax returns as required.
8. Have your healthcare provider complete the healthcare provider section, which may include a prescription and medical history.
9. Review the entire application for completeness and accuracy.
10. Sign and date the application before submission.
11. Send the completed application, along with all required documents, to the designated address provided in the instructions.

Who needs Bristol-Myers Squibb Patient Assistance Program Application?

1. Individuals who are uninsured or underinsured and cannot afford their prescribed medications.
2. Patients diagnosed with specific conditions treated by Bristol-Myers Squibb medications.
3. Low-income individuals or families in need of financial assistance to access necessary treatments.

People Also Ask about

What do I do if I can't afford ELIQUIS?

The hospital or your doctor can get you a coupon for the first month free. Call the Eliquis number and if she meets income requirements the company will discount the cost. GoodRX and Single Care members get a bit of a discount, about $70.00 off. These are free to join.

How do I get ELIQUIS for $10 a month?

Eligible patients who present an activated Co-pay Card together with a valid prescription for ELIQUIS at participating pharmacies may pay as little as $10 per 30-day supply (up to 74 tablets for the first fill and up to 60 tablets for all subsequent fills) for up to 24 months, subject to a maximum annual benefit of

How can I get help paying for my Eliquis?

Eligibility and enrollment Be a US citizen or legal resident. Have a total household income at or below 400% of the federal poverty level. Must be uninsured, or have Medicare. Note: if you have private or commercial insurance, you are not eligible for the PAP.

What are the income requirements for ELIQUIS patient assistance program?

Eliquis Patient must be at or below 300% federal poverty level to qualify. View federal poverty guidelines. Medications can be shipped to the patient's home. Applications are good for 1 year from the date approved by the program.

For pdfFiller’s FAQs

What is Bristol-Myers Squibb Patient Assistance Program Application?

The Bristol-Myers Squibb Patient Assistance Program Application is a form that patients can fill out to request access to medications at no cost or reduced cost from Bristol-Myers Squibb for those who meet specific eligibility criteria.

Who is required to file Bristol-Myers Squibb Patient Assistance Program Application?

Patients who are uninsured, underinsured, or facing financial hardships that prevent them from affording their prescribed medications are required to file the application.

How to fill out Bristol-Myers Squibb Patient Assistance Program Application?

To fill out the application, patients must complete personal and financial information sections, including income details, the medications needed, and signatures to authorize the release of medical information.

What is the purpose of Bristol-Myers Squibb Patient Assistance Program Application?

The purpose of the application is to ensure that eligible patients can access necessary medications without financial burden and to provide assistance to those who are struggling to afford their treatments.

What information must be reported on Bristol-Myers Squibb Patient Assistance Program Application?

The application must report personal identification details, income and household size, medication prescriptions, healthcare provider information, and any insurance coverage status.