Allergan patient assistance program application 2021-2026

1. Click ‘Get Form’ to open the allergan patient assistance program application 2021 in the editor.
2. Begin by filling in the 'Attn' and 'From' sections with the appropriate contact information. Ensure that all fields are completed accurately.
3. In the 'Patient' section, provide the patient's full name, date of birth, and social security number. This information is crucial for eligibility verification.
4. Next, indicate the gross annual household income and number of persons in the household. Attach a copy of income verification documents as specified.
5. Check any applicable insurance programs under which the patient is enrolled. This helps determine coverage options for medications requested.
6. Both the patient and healthcare provider must sign and date their respective sections to validate the application before submission.
7. Finally, fax or mail the completed application along with income documentation to the address provided at the top of the form.

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