Lilly Cares Foundation Patient Assistance Program
The Lilly Cares Foundation offers a Patient Assistance Program that provides vital resources and support for patients in need. This file includes essential forms for prescription management and product replacement requests. Ensure you follow the guidelines outlined for efficient processing of your requests.
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How do I fill this out?
Filling out the Lilly Cares Foundation Patient Assistance Program form is straightforward. Gather your patient and prescriber details, ensuring all necessary information is complete and accurate. Once filled, submit the form as instructed for prompt assistance.
How to fill out the Lilly Cares Foundation Patient Assistance Program?
1
Collect patient and prescriber information.
2
Fill in the required fields in the form.
3
Double-check for accuracy and completeness.
4
Submit the form either by fax or mail.
5
Retain a copy for your records.
Who needs the Lilly Cares Foundation Patient Assistance Program?
1
Patients requiring medication assistance from Lilly.
2
Healthcare providers documenting administration details for patients.
3
Pharmacies managing patient prescription refills.
4
Insurance companies processing patient claims.
5
Support staff assisting in patient care coordination.
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What are the instructions for submitting this form?
To submit this form, fax it to 1-888-242-6230 or mail it to Lilly Cares Foundation, PO Box 13185, La Jolla, CA 92039. Ensure that all required fields are filled out completely before submission. Retain a copy of the form for your records to track your request.
What are the important dates for this form in 2024 and 2025?
Important dates for submitting the form include the beginning of each enrollment period and deadlines for proactive provision requests. For accurate processing, ensure all submissions are made in a timely manner as outlined in the guidelines provided. Always check for updates to deadlines frequently.
What is the purpose of this form?
The purpose of this form is to facilitate the administration of medication provided through the Lilly Cares Foundation's Patient Assistance Program. It ensures that patients receive necessary medications while complying with all healthcare regulations and documentation requirements. Additionally, it serves as a record for prescribers and insurers to support the patient's health journey effectively.
Tell me about this form and its components and fields line-by-line.
- 1. Prescriber Name and Title: The name and title of the healthcare provider prescribing the medication.
- 2. Clinic or Hospital Name: The name of the clinic or hospital where the patient is being treated.
- 3. Patient Name/SR Number: The patient's name and a unique service request number for tracking.
- 4. Dosage: Details regarding the required dosage of the medication prescribed.
- 5. Physician Signature: The signature of the prescriber, certifying the information provided.
What happens if I fail to submit this form?
Failure to submit the form can result in delays in medication assistance for the patient. It’s crucial to complete and send the form accurately to ensure timely support from Lilly Cares. Without proper submission, the patient may face interruptions in their treatment plan.
- Delays in Medication Assistance: Without submission, the patient may not receive their critical medication on time.
- Insurance Complications: Incomplete forms can lead to issues with insurance claims related to the medication.
- Regulatory Non-compliance: Failure to follow submission guidelines may lead to compliance issues with healthcare regulations.
How do I know when to use this form?
- 1. Patient Medication Assistance: For patients requesting assistance in obtaining their prescribed drugs.
- 2. Pharmacy Supply Requests: When pharmacies need documentation to manage supply and reimbursements.
- 3. Insurance Documentation: Facilitates documentation needed for insurance claims related to medications.
Frequently Asked Question
How do I access the Lilly Cares form?
You can easily find the Lilly Cares form on PrintFriendly. It is available for editing and downloading at your convenience.
Can I edit the Lilly Cares form after downloading?
Yes, the form can be edited on PrintFriendly before you download it.
What information do I need to fill out the form?
You will need patient and prescriber information along with medication details.
Is it possible to submit the form online?
Currently, submissions need to be made via fax or mail as directed on the form.
How do I ensure my form is complete?
Double-check all entries for accuracy and review the guidelines provided on the form.
What should I do if I make a mistake?
You can edit the PDF on PrintFriendly and correct any errors before final submission.
When can I expect assistance after submitting?
Response times may vary, but Lilly Cares aims to process submissions promptly.
Can I share the form with others?
Yes, you can share your document easily using the sharing options on PrintFriendly.
Is there a cost associated with the patient assistance?
The Lilly Cares Program provides assistance at no charge to eligible patients.
How do I contact Lilly Cares for more help?
For assistance, call Lilly Cares at 1-800-545-6962.
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