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- Click ‘Get Form’ to open the Lyme TAP form 2012 in the editor.
- Begin by filling out your personal information, including your name, address, and contact details. Ensure all entries are clear and legible.
- Provide your healthcare provider's information. This includes their name, address, and phone number. This section is crucial for verifying medical necessity.
- In the Diagnostic Test Information section, list the tests performed along with their costs. Indicate if you have been tested previously.
- Complete the Statement of Financial Need by selecting the basis for your application (low income or other circumstances) and attach necessary documentation such as your 1040 Federal tax return.
- Finally, ensure that both you and your healthcare provider sign the application to certify its accuracy before submitting it via fax or email.
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