UCB Patient Assistance Program Application
This application form is designed for patients seeking assistance from UCB's Patient Assistance Program. It provides step-by-step guidance to access medications like CIMZIA, VIMPAT, and more. Please ensure all sections are completed accurately to avoid delays.
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How do I fill this out?
To fill out the UCB Patient Assistance Program Application, begin by gathering necessary personal and prescription information. Ensure that all sections are completed to facilitate processing. If you have any questions, reach out to UCBCares for assistance.
How to fill out the UCB Patient Assistance Program Application?
1
Gather your personal information and prescription details.
2
Complete Sections 1 and 2 as the patient or authorized representative.
3
Have your physician fill out Section 3.
4
Ensure all sections are signed where required.
5
Submit the application along with the necessary documents.
Who needs the UCB Patient Assistance Program Application?
1
Patients who are uninsured and need medication assistance.
2
Individuals on Medicare Part D who require help with prescription coverage.
3
Patients prescribed CIMZIA or similar products who need financial support.
4
Healthcare providers seeking assistance for eligible patients.
5
Authorized representatives helping patients fill out the application.
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What are the instructions for submitting this form?
To submit the UCB Patient Assistance Program Application, please ensure all sections are filled out completely. Applications can be sent via fax to (855) 880-5262 or mailed to UCB, Inc., at 1330 Enclave Parkway, Suite 125, Houston, TX 77077. For any inquiries, contact us at (877) 785-8906 or via email at ucb-pap@cardinalhealth.com.
What are the important dates for this form in 2024 and 2025?
Important dates for the UCB Patient Assistance Program in 2024 and 2025 will depend on the program's ongoing availability. Applications should be submitted promptly to avoid any lapses in assistance. Always check for updates on program eligibility and deadlines.
What is the purpose of this form?
The UCB Patient Assistance Program Application aims to provide eligible patients with access to necessary medications. It targets those facing financial hardships or lacking insurance coverage for prescriptions. The form simplifies the process for patients and healthcare providers to ensure timely assistance.
Tell me about this form and its components and fields line-by-line.
- 1. Patient First Name: Enter the patient's first name.
- 2. Patient Last Name: Enter the patient's last name.
- 3. Address: Provide the patient's residential address.
- 4. City: Specify the city of residence.
- 5. State: Indicate the state of residence.
- 6. Zip: Insert the zip code.
- 7. Phone: Add the patient's contact phone number.
- 8. Date of Birth: Record the patient's date of birth.
- 9. Physician's Signature: Obtain the signature of the prescribing physician.
- 10. Date: Enter the date when the application is signed.
What happens if I fail to submit this form?
Failure to submit this form accurately may result in delays or denial of assistance. It is crucial to ensure all required fields are filled and that the prescription is valid.
- Incomplete Information: Missing fields can lead to application rejection.
- Invalid Prescription: Submitting an invalid prescription may disqualify the request.
- Errors in Details: Incorrect information can further delay the process.
How do I know when to use this form?
- 1. Applying for Medication Assistance: Use this form to access necessary medications if you are financially eligible.
- 2. Updating Your Application: If your circumstances change, this form can be used to update your information.
- 3. Consultation with Healthcare Provider: Healthcare providers can leverage this application for eligible patients.
Frequently Asked Questions
What is the UCB Patient Assistance Program Application?
It is a form designed to assist patients in accessing medications through UCB's assistance program.
How can I edit this application form?
You can upload the PDF to PrintFriendly and use the editing tools to make adjustments.
What should I include when submitting the form?
Include a valid prescription along with the completed application form.
Is there a cost associated with this application?
No, the application is free for eligible patients.
Who is eligible for the Patient Assistance Program?
Eligibility is primarily for uninsured patients or those with limited insurance coverage.
How do I contact UCB about my application?
You can contact UCBCares by calling 844-599-CARE (2273) for inquiries.
Can I apply on behalf of someone else?
Yes, authorized representatives can complete the application for patients.
What happens after I submit my application?
Your information will be verified, and you will be notified about your eligibility.
How long is the application approval valid?
Approvals may be valid for up to 12 months, subject to verification.
What if I don't meet the minimum requirements?
Contact UCBCares to explore other potential financial resources.
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