Phone: 866-310-7549 MF 8 am8 pm ET Novo Nordisk, Inc Novo Nordisk-2025

1. Click ‘Get Form’ to open the Novo Nordisk Patient Assistance Program Application in the editor.
2. Begin by filling out the Patient Section. Enter the patient's first name, last name, date of birth, and contact information. Ensure all fields marked with an asterisk are completed.
3. In the Insurance section, indicate whether the patient has any form of prescription drug coverage. If yes, check all applicable options and provide necessary details.
4. Complete the Income section by entering total household annual income and number of dependents. Attach proof of income as required.
5. For the Prescriber Section, ensure that all prescriber information is accurately filled out, including signature and date.
6. Review all sections for completeness. Sign and date where required before submitting your application via mail or fax.

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