Home
Forms Library
Ucb patient assistance program application form

Ucb patient assistance program application form 2025

ucb patient assistance program application form Preview on Page 1

See details

4.8 out of 5

44 votes

The UCB Patient Assistance Program Application provides financial assistance to eligible patients in the U.S. who require access to specific UCB medications, including CIMZIA®, BRIVIACT®, VIMPAT®, NEUPRO®, and KEPPRA®. To qualify, patients must meet certain medical and financial criteria, such as being uninsured or having no prescription coverage, and their household income must not exceed 300% of the Federal Poverty Limit. The application process requires completion by both the patient and their prescribing physician, along with necessary documentation.

Here's how it works

01. Edit your ucb patient assistance program application form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send ucb patient assistance form pdf via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out ucb patient assistance program application form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the UCB Patient Assistance Program application in the editor.
Begin with Section 1, 'Patient Information.' Fill in all required fields clearly, including your name, address, and contact information. Ensure you indicate if you reside in the U.S. and provide a valid ID number if applicable.
Proceed to Section 2, 'Income Information.' Accurately list your gross monthly household income from all sources. Remember to sign and date this section as it is crucial for processing your application.
In Section 3, have your physician complete the prescription information. Ensure they include their contact details and sign off on the application.
Review all sections for completeness before submitting. Use our platform’s features to save or share your completed form easily.

Start filling out your UCB Patient Assistance Program application today for free using our platform!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who funds patient assistance programs?

Pharmaceutical manufacturers may sponsor patient assistance programs (PAPs) that provide financial assistance or drug free product (through in-kind product donations) to low income individuals to augment any existing prescription drug coverage.

What is the Keppra medication assistance program?

A patient assistance program is a special service offered by all major drug companies. If you cant afford your medications, drug manufacturers may offer benefits like: Prescription medicine free of charge or at low cost. Medicine sent to your home, your doctors office, or your pharmacy.

How can I get Briviact for free?

The BRIVIACT Patient Assistance Program may provide medication at no cost to eligible patients who are unable to pay for their BRIVIACT prescription. To find out if you might be eligible for assistance, please call UCBCares at 844-599-CARES (2273) or email ucbcares@ucb.com.

What if I cant afford my seizure medication?

Our Patient Assistance Programs are intended for people that live in the United States, have limited or no health insurance coverage and demonstrate qualifying financial need. In 2023, we assisted more than 218,000 people. Applying to myAbbVie Assist is simple.

Who is eligible for the AbbVie patient assistance program?

In order to qualify for UCB patient assistance or co-pay assistance, you must: Be a resident of the United States, the District of Columbia, or Puerto Rico. Have no insurance that provides prescription coverage, although you may still qualify if you are enrolled in a Medicare Part D plan.

ask ucbcares

UCB Patient Assistance Program application PDF UCB BIMZELX Patient assistance Program UCB Patient Assistance Program VIMPAT application CIMZIA Patient Assistance Program application UCB cares Enrollment form UCB CIMZIA Patient Assistance Program UCB Patient Assistance Program phone Number CIMZIA Patient Assistance application pdf

What is the number for UCB patient assistance program?

If you believe you do not meet the minimum requirements listed above, please contact UCBCares by calling 844-599-CARE (2273) to determine whether other financial resources may be available to you.

What is the patient assistance program for Keppra?

Program information: The KeppraⓇ Patient Assistance Program is intended to provide temporary assistance to patients who do not qualify for or have benefits through private insurance or a government funded program, and who do not have other sufficient means to pay for their medication.