Paragard patient assistance program 2026

1. Click ‘Get Form’ to open the ParaGard Patient Assistance Program Qualification Form in the editor.
2. Begin by filling out the 'Patient Information' section. Provide your first and last name, social security number, address, date of birth, and current gross annual household income. Ensure that all information is accurate as it will be used to determine eligibility.
3. In the 'Insurance and Prescription Coverage' section, check all applicable boxes regarding your insurance status. If you are uninsured, make sure to indicate this clearly.
4. Sign the 'Patient’s Verification and Signature' section. This confirms that the information provided is complete and accurate. Remember to date your signature.
5. Next, have your healthcare professional complete their section by providing their details and signing off on the form. They must also include their state license number if submitting for the first time.
6. Finally, ensure that both forms—the Qualification Form and Authorization to Disclose Protected Health Information—are completed and submitted together via fax or mail as instructed.

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