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01. Edit your alcon patient assistance program online
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How to use or fill out alcon patient assistance program with our platform
- Click ‘Get Form’ to open the Alcon Patient Assistance Program in the editor.
- Begin with Section 1: Patient Information. Fill in your name, phone number, address, and date of birth. Ensure you provide your Social Security Number and marital status.
- Complete the Insurance Information section. Indicate if you have insurance and provide details such as the insurance company name and policy ID.
- In the Financial Information section, enter your total annual income and include copies of your most recent Federal Income Tax return or proof of income.
- Sign the Patient Authorization at the bottom of Section 1 to confirm that you authorize your healthcare provider to release necessary health information.
- Move to Section 2: Healthcare Provider Section. Your healthcare provider will need to fill out their information, including their license number and facility details.
- Ensure that both you and your healthcare provider sign the form before submitting it via fax or mail as instructed.
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