Bi cares 2026

1. Click ‘Get Form’ to open the bi cares application in the editor.
2. Begin with Section 1: Patient Information. Fill in your first name, last name, address, city, state, zip code, and preferred daytime phone number. Ensure all details are printed clearly in black or blue ink.
3. Proceed to Section 2: Patient Financial Information. Indicate the number of people living in your household and provide your total household income and assets.
4. In Section 3: Insurance Information, answer the questions regarding your insurance status by circling 'Yes' or 'No' as applicable.
5. Complete Section 4: Patient Attestation & HIPAA Authorization by signing and dating the form. This confirms that all information provided is accurate.
6. Sections 5 and 6 require your prescriber’s information and prescription details. Ensure these sections are filled out completely by your healthcare provider.
7. Once completed, review all sections for accuracy before submitting the application via mail or fax as indicated at the end of the form.

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