Allergan Patient Assistance Program Application 2026

1. Click ‘Get Form’ to open the Allergan Patient Assistance Program Application in our editor.
2. Begin with Section 1, 'Prescriber Information.' Fill in the prescriber's name, NPI, designation, state license, DEA, office name, contact name, phone number, and shipping address.
3. Proceed to Section 2 for 'Patient Information.' Enter the patient's first and last name, date of birth, gender, phone number, and shipping address.
4. In Section 3, 'Medication Request,' specify the product name, strength, quantity needed, directions for use, and any allergies. Ensure this section is completed by a licensed prescriber.
5. For patients filling out Section 6 on 'Financial Information,' provide total monthly income and household details. Attach proof of income as required.
6. Complete Section 7 regarding 'Insurance Information.' Indicate if you have insurance coverage and provide relevant details about your medical expenses.
7. In Section 8, ensure that both patient consent and signature are provided. Review HIPAA authorization before signing.
8. Finally, review all sections for completeness before submitting the application via fax or mail as instructed at the end of the form.

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