Bristol myers squibb patient assistance application 2022 pdf-2026

1. Click ‘Get Form’ to open the Bristol-Myers Squibb Patient Assistance Application in the editor.
2. Begin by filling out the Patient Information section. Enter your first name, last name, middle initial, date of birth, and contact details including your address and phone number.
3. In the Patient Eligibility Information section, provide your total annual household income and household size. Ensure you attach proof of income as required.
4. Complete the Healthcare Provider Information section. The prescribing practitioner must fill in their details, including state license number and shipping address.
5. Select the requested medication from the list provided and indicate the quantity per day. If applicable, confirm if this is a change in dosage for an existing member.
6. Review all sections for completeness. Sign where indicated and ensure that all necessary attachments are included before submitting.

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