Otsuka patient assistance application form 2025

1. Click ‘Get Form’ to open it in our editor.
2. Begin with Section 1, the Patient Authorization. Read the authorization carefully and sign where indicated. This section allows your protected health information to be shared with Otsuka.
3. Proceed to Section 2, Patient Demographic Information. Fill in your first name, last name, date of birth, and contact details. Ensure all required fields are completed.
4. In Section 3, provide your insurance information. If you have insurance, attach copies of your cards or fill out the necessary details if not attaching them.
5. Complete Section 4 regarding Insurance Eligibility Information by answering questions about your coverage status.
6. Fill out Section 5 for Financial Eligibility Information, detailing your annual household income and prescription costs.
7. Finally, Sections 6 and 7 must be completed by your prescribing healthcare provider. Ensure they provide their signature and any required documentation.

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