Alcon patient assistance program 2026

1. Click ‘Get Form’ to open the Alcon Patient Assistance Program in the editor.
2. 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.
3. Complete the Insurance Information section. Indicate if you have insurance and provide details such as the insurance company name and policy ID.
4. 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.
5. Sign the Patient Authorization at the bottom of Section 1 to confirm that you authorize your healthcare provider to release necessary health information.
6. Move to Section 2: Healthcare Provider Section. Your healthcare provider will need to fill out their information, including their license number and facility details.
7. Ensure that both you and your healthcare provider sign the form before submitting it via fax or mail as instructed.

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