Lilly cares re enrollment application 2026

1. Click ‘Get Form’ to open the Lilly Cares re enrollment application in the editor.
2. Begin by filling out the Patient Section. Enter your name, address, date of birth, and contact information accurately. Ensure that all details are correct as this information is crucial for processing your application.
3. In the Patient Income Information section, indicate the number of family members in your household and provide your total gross household income. Remember to prepare copies of proof-of-income documents as specified.
4. Next, review and sign the Patient Certification. This confirms that you meet all eligibility requirements for the program. Make sure to read through each statement carefully before signing.
5. Once completed, have your doctor fill out the Doctor Section. They will need to provide their information and confirm your prescription needs.
6. Finally, save your completed application and submit it via mail or fax using the provided contact details at the top of the form.

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