Bristol-Myers Squibb Patient Assistance Application
This file contains the application form for the Bristol-Myers Squibb Patient Assistance Foundation. It details eligibility criteria and instructions for applying for free medication. Ideal for patients seeking financial support for prescribed medicines.
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How do I fill this out?
To fill out this application, please ensure you have all required information at hand. Begin by completing the Patient Information section accurately. Once finished, sign and date the Patient Agreement and Consent before submitting the form.
How to fill out the Bristol-Myers Squibb Patient Assistance Application?
1
Gather all necessary personal and insurance information.
2
Complete the Patient Information and Insurance sections diligently.
3
Provide details about your household income.
4
Sign and date the Patient Agreement and Consent section.
5
Submit the application by mail or fax as directed.
Who needs the Bristol-Myers Squibb Patient Assistance Application?
1
Patients without insurance who need medication assistance.
2
Individuals with high prescription costs relative to their income.
3
People receiving care from a licensed US physician.
4
Residents of the USA, Puerto Rico, or the U.S. Virgin Islands.
5
Those needing help applying for pharmaceutical assistance programs.
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Review all entered data for accuracy.
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Download the edited PDF or proceed to sign it.
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Share the final document as needed.
What are the instructions for submitting this form?
To submit this form, you can send it via mail to Bristol-Myers Squibb Patient Assistance Foundation, PO Box 220769, Charlotte, NC 28222-0769. Alternatively, fax your completed application to 800-736-1611. Ensure all required details are thoroughly filled out to avoid delays.
What are the important dates for this form in 2024 and 2025?
Important dates for the application process include yearly assessments of eligibility and income limits set by the foundation, which may change annually. Ensure to check for updates regularly. The application should be submitted well in advance of any required prescription renewals.
What is the purpose of this form?
The purpose of this form is to offer assistance to eligible patients needing medication support. This application enables individuals to access vital medications without financial burden. By submitting the form, patients can seek help from the Bristol-Myers Squibb Patient Assistance Foundation in obtaining the medicines they need.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Basic information about the patient including name, birthdate, and address.
- 2. Insurance Information: Details regarding the patient's insurance coverage and associated costs.
- 3. Household Size & Income: Information on the number of individuals living in the household and their combined income.
- 4. Patient Agreement and Consent: A section for the patient to agree to the terms and conditions of the application.
What happens if I fail to submit this form?
If the form is not submitted, individuals may miss out on vital financial support for their medications. Incomplete or incorrect applications can lead to delays or denial of assistance.
- Delayed Response: Incomplete submissions may lead to a slower processing time for assistance.
- Denial of Assistance: Failure to meet eligibility requirements can result in not receiving the necessary medications.
- Increased Financial Strain: Without assistance, patients may struggle to afford necessary medications.
How do I know when to use this form?
- 1. Medication Assistance: For patients needing help obtaining essential medications.
- 2. Financial Support: To request financial support from the Bristol-Myers Squibb Patient Assistance Foundation.
- 3. Eligibility Verification: For establishing eligibility based on household income and insurance coverage.
Frequently Asked Questions
How do I start filling out the application?
Begin by accessing the PDF on PrintFriendly and gathering your required personal information.
Can I edit the form after downloading it?
Yes, you can edit the form directly on PrintFriendly before downloading.
Is there a fee to apply through this program?
No, applying through the Bristol-Myers Squibb Patient Assistance Foundation is free.
What if I don’t have insurance?
Even without insurance, you may still qualify for assistance if you meet the eligibility criteria.
How do I submit the completed form?
You can submit the completed form by mail or fax to the designated address.
What medications are covered under this assistance?
The program includes medications such as ELIQUIS, NULOJIX, and ORENCIA.
How can I contact BMSPAF for questions?
You can reach BMSPAF at 800-736-0003 during operational hours.
Do I need to reapply for assistance?
Yes, if you are enrolled, you will have to reapply periodically.
What information do I need for my application?
You will need personal, income, and insurance information when filling out the application.
Can I save my progress on the form?
While you can edit and download, saving progress is not currently an option.
