Edit, Download, and Sign the Abbott Patient Assistance Foundation Application Form
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How do I fill this out?
To fill out the application, follow these steps carefully. Ensure all required sections are completed and appropriate documentation is attached. Submit the application along with the necessary signatures.
How to fill out the Abbott Patient Assistance Foundation Application Form?
1
Complete all sections of the application form.
2
Attach proof of income for all household members.
3
Obtain signatures from both the prescriber and the patient.
4
Include copies of Medicare or Medicaid denial letters, if applicable.
5
Submit the completed application and documentation via fax or mail.
Who needs the Abbott Patient Assistance Foundation Application Form?
1
Uninsured patients needing specific Abbott medications.
2
Patients with no access to alternative coverage or funding.
3
Individuals who have been denied Medicaid or Medicare.
4
Households experiencing financial difficulties.
5
Healthcare providers assisting eligible patients.
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1
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2
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What are the instructions for submitting this form?
To submit the form, ensure all sections are filled out completely, attach proof of income, and include copies of Medicare or Medicaid denial letters if applicable. Obtain signatures from both the patient and prescriber. Fax the completed form to 1-866-898-1473 or mail it to Abbott Patient Assistance Foundation, P.O. Box 270, Somerset, NJ 08876. For additional assistance, contact 1-800-222-6885.
What are the important dates for this form in 2024 and 2025?
Ensure timely submission of the form annually or as advised for reapplication.
What is the purpose of this form?
The purpose of this form is to provide patients experiencing financial difficulties with access to Abbott medications at no cost. By submitting this form, patients can apply for assistance and get necessary medications shipped to their prescriber's office. The form requires detailed financial information and necessary signatures to verify eligibility for the program.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the patient applying for assistance.
- 2. Gender: Gender selection: Male or Female.
- 3. Telephone Number: Contact number for the patient.
- 4. Shipping Address: Address where the medications will be shipped.
- 5. City, State, Zip: City, state, and zip code of the shipping address.
- 6. Date of Birth: Patient's date of birth.
- 7. Social Security Number: Patient’s social security number.
- 8. Medicare Enrollment: Checklist for Medicare enrollment status.
- 9. Prescription Drug Coverage: Information about any prescription drug coverage.
- 10. Monthly Income: Total monthly income for the entire household.
- 11. Household Information: Details about the number of people in the household.
- 12. Personal Representative Authorization: Authorization details if another person is authorized to discuss the application.
- 13. Healthcare Provider Information: Name, designation, license number, and contact information of the healthcare provider.
- 14. Medication Information: Details about the medication being prescribed.
- 15. Signature Section: Sections for the patient's and prescriber's signatures and dates.
What happens if I fail to submit this form?
Failing to submit the form will result in ineligibility for the medication assistance program.
- Ineligibility for Medication Assistance: Without submission, you cannot access free medications from the program.
- Delay in Receiving Medication: Failure to submit on time may cause delays in receiving necessary medication.
- Additional Documentation Requests: You may need to provide additional documentation if the submission is incomplete or late.
How do I know when to use this form?
- 1. Uninsured Patients: For patients without insurance needing specific Abbott medications.
- 2. Medicare Denial: If you have been denied Medicaid or Medicare coverage.
- 3. No Alternative Funding: When there are no other funding sources available for medication.
- 4. Financial Hardship: If experiencing financial difficulty in purchasing medications.
- 5. Healthcare Provider Assistance: To assist patients in accessing necessary medications.
Frequently Asked Question
How do I fill out the Abbott Patient Assistance Foundation Application?
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What documents are needed to accompany the form?
You need to attach proof of income and any relevant Medicare or Medicaid denial letters.
Can I reorder medication using this form?
Yes, the prescriber or office staff can reorder medication 3 weeks prior to needing more by using this form.
Who should sign the form?
Both the patient and the prescriber need to sign the application form.
What is the contact information for submitting the form?
Fax: 1-866-898-1473, Phone: 1-800-222-6885, Mail: Abbott Patient Assistance Foundation, P.O Box 270, Somerset, NJ 08876.
How do I know if I am eligible for assistance?
Eligibility will be determined upon review of the completed application, and both the prescriber and patient will be notified of the decision.
What happens if my state license number changes?
You must notify the Abbott Patient Assistance Foundation in writing immediately if your state license number changes.
