To submit this form, complete all required fields including patient and prescriber information, medication details, and signatures. Fax the completed form to 1-844-431-6650 or mail it to Lilly Cares Foundation Patient Assistance Program, PO Box 13185, La Jolla, CA 92039. For further assistance, contact Lilly Cares at 1-800-545-6962. Ensure timely submission to avoid delays in medication access.

Ensure you submit this form before the prescription expiration date in 2024 and 2025. Check with the Lilly Cares Foundation for specific program deadlines. Timely submission is crucial for uninterrupted medication access.

The purpose of the Lilly Cares Foundation Patient Assistance Program Diabetes Prescription Form is to facilitate the prescription of diabetes medications provided by Lilly. This form ensures that eligible patients receive the necessary medication to manage their diabetes effectively. It helps prescribers and patients alike by streamlining the process of accessing medications through the Lilly Cares program. By using this form, prescribers can accurately record patient information and their prescribed medications, ensuring that patients receive the correct dosages and quantities. This systematic approach not only improves patient care but also helps in maintaining compliance with state laws and regulations regarding prescription medications. Ultimately, the Lilly Cares Foundation Patient Assistance Program Diabetes Prescription Form provides a structured and efficient way to manage diabetes treatment. It supports patients in their journey towards better health by ensuring they have access to essential medications, while also assisting healthcare providers in delivering high-quality care.

• 1. Patient Name: The full name of the patient receiving the prescription.
• 2. Address: The residential address of the patient.
• 3. City: The city where the patient resides.
• 4. State: The state where the patient resides.
• 5. Zip Code: The postal code for the patient's address.
• 6. Phone: The contact phone number for the patient.
• 7. Ship to Address: The address where the medications should be shipped, if different from the patient’s address.
• 8. Drug Allergies: Any known drug allergies of the patient.
• 9. Other Medications: Any other medications the patient is currently taking.
• 10. RX: Authorization for Lilly Cares to act on behalf of the patient for transmitting the prescription.
• 11. Medication List: A list of available medications including Baqsimi, Humalog, Basaglar, etc., with fields for dosage, quantity, and refills.
• 12. Prescriber Signature: The signature of the prescriber authorizing the prescription.
• 13. Printed Prescriber Name: The printed name and title of the prescriber.
• 14. State License Number: The license number and state of the prescriber.
• 15. Prescriber Office/Clinic Name and Shipping Address: The office or clinic name and address where the prescriber practices.
• 16. NPI#: The National Provider Identifier number for the prescriber.
• 17. FAX: The fax number for the prescriber's office.
• 18. Phone: The contact phone number for the prescriber's office.

Failure to submit this form may result in delays or denial of access to necessary diabetes medications. It is essential to complete and submit the form accurately and promptly to ensure uninterrupted medication supply.

• Medication Delays: Prescription processing can be delayed, leading to interruptions in medication supply.
• Access Denial: The patient may be denied access to medications if the form is not submitted correctly.
• Compliance Issues: Failure to comply with state laws and requirements may result in legal issues for the prescriber.

• 1. Initial Prescription: When prescribing medication for the first time to a patient eligible for the Lilly Cares program.
• 2. Medication Refill: When a patient requires a refill of their existing diabetes medication prescription.
• 3. Medication Change: If there is a need to change the medication or dosage for a patient.
• 4. Emergency Medication: When prescribing emergency medication such as Glucagon for an immediate need.
• 5. Program Enrollment: For enrolling a new patient into the Lilly Cares patient assistance program.