Salix patient assistance program 2026

1. Click ‘Get Form’ to open the Salix Patient Assistance Program application in the editor.
2. Begin with Section I, 'Patient Information.' Fill in your name, contact details, and confirm your residency status. Ensure all fields are completed clearly.
3. Proceed to Section II for 'Prescriber Information.' The prescriber must provide their details, including NPI number and state license. This section requires a signature for attestation.
4. In Section IV, 'Financial Information,' list all sources of household income and total medical expenses. Attach proof of income as specified.
5. Complete Section V regarding insurance information. Indicate any coverage you may have and attach relevant documentation if applicable.
6. Review all sections for completeness. If any field does not apply, write 'N/A.' Once finalized, save your document and follow the instructions to mail or fax it to the provided address.

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