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How do I fill this out?
If you need help filling out this form, don't worry, we're here to guide you through the process. Follow the steps provided below for a smooth and complete application. Ensuring you fill out each section accurately will help us determine your eligibility for the AbbVie Patient Access Support programs.
How to fill out the HUMIRA® Patient Access and Financial Support Information?
1
Carefully read the terms of participation, privacy notice, financial information, and HIPAA authorizations on pages 1-3.
2
Print and complete the enrollment form on page 4.
3
Provide your consent for eligibility determination by checking the boxes in Section 5 and confirm your understanding of the Terms of Participation by providing your signature and date.
4
If you have health insurance, include front and back copies of all insurance cards.
5
Keep a copy of this application for your records.
Who needs the HUMIRA® Patient Access and Financial Support Information?
1
Patients in need of financial assistance for their HUMIRA® medication.
2
Prescribers looking to enroll patients in the AbbVie Patient Access Support program.
3
Individuals who need help navigating insurance coverage for their medication.
4
Patients seeking information on free medication programs.
5
Caregivers assisting patients with their medication access and financial support.
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1
Upload your PDF document to PrintFriendly.
2
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5
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What are the instructions for submitting this form?
Submit the completed form along with required documentation via one of the following methods: Fax to AbbVie at 1-866-250-2803, mail to AbbVie Patient Access Support, D-617927, AP5 NE, 1 N. Waukegan Rd., North Chicago, IL 60064, or complete the form electronically at www.AbbVie.com/PAS. For any questions, please call 1-800-222-6885. My advice: Ensure all sections are filled out accurately and provide all required documents to expedite the review process.
What are the important dates for this form in 2024 and 2025?
Please refer to any updates on the AbbVie website or contact their support number for important dates related to the application and eligibility process for 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to provide patients with access to financial support and medication assistance programs for their HUMIRA® treatment. This form helps determine eligibility for various support programs offered by AbbVie. By completing this form, patients and their prescribers can ensure that they receive the necessary assistance to manage their treatment costs.
Tell me about this form and its components and fields line-by-line.
- 1. Terms of Participation: Details the terms and conditions for participating in the Patient Access Support programs.
- 2. Privacy Notice: Outlines how personal data will be collected, used, and retained by AbbVie.
- 3. Financial Information: Requests financial details to assess eligibility for assistance programs.
- 4. HIPAA Authorization: Allows the disclosure of protected health information to AbbVie for program administration.
- 5. Enrollment Form: A form that must be completed and signed to apply for the program.
What happens if I fail to submit this form?
If you fail to submit the form, you may not be eligible for the Patient Access Support programs, and you may not receive the necessary financial assistance for your medication.
- Ineligibility for Assistance: Failing to submit the form can result in not qualifying for AbbVie's financial support programs.
- Medication Costs: Without assistance, you may face higher out-of-pocket costs for your medication.
- Treatment Disruption: Not receiving support could lead to interruptions in your treatment plan.
How do I know when to use this form?
- 1. Applying for Financial Assistance: When you need help covering the costs of your medication.
- 2. Accessing Free Medication Programs: To apply for programs that provide HUMIRA® at no cost.
- 3. Insurance Challenges: If you need support navigating insurance coverage for your treatment.
- 4. Enrollment in Patient Support Programs: To enroll in AbbVie's various patient assistance programs.
- 5. Updating Information: When you need to update your financial or insurance information with AbbVie.
Frequently Asked Question
How do I fill out the HUMIRA® Patient Access Support form?
Carefully read the instructions, print and complete the required sections, provide your consent and signatures, attach insurance card copies if applicable, and keep a copy for your records.
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You can use our built-in signature feature to add your electronic signature directly to the form.
How do I submit the completed form?
You can fax, mail, or submit the form online using the provided contact information in the document.
What should I do if I need help with the form?
Call the provided support number or visit the website for additional resources and assistance.
Can I save my progress while filling out the form?
Yes, you can save your progress and return to complete the form later.
Are there any eligibility requirements for the program?
Yes, eligibility is based on financial and insurance criteria detailed in the document.
How do I share the completed PDF?
You can share the document via email or generate a shareable link using PrintFriendly's sharing options.
Is there a privacy notice included in the form?
Yes, the privacy notice details how your personal data will be collected and used.
What happens if I do not sign the HIPAA authorization?
If you do not sign the HIPAA authorization, you cannot take part in the program.
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