18005456962 2026

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Click ‘Get Form’ to open the Lilly Cares Patient Assistance Program application in the editor.
Begin by filling out the Patient Section. Enter your name, address, date of birth, and contact information accurately.
In the Patient Income Information section, indicate the number of family members and your total gross household income. Ensure you have proof of income documents ready to upload.
Review the Patient Certification carefully. Confirm that all statements are true and sign where indicated.
Next, have your doctor complete the Doctor Section. They will need to provide their details and confirm your eligibility for the program.
Once both sections are completed, save your form and either mail or fax it along with copies of your proof-of-income documents to the Lilly Cares program using the provided contact information.

Start filling out your application today for free on our platform!