Novartis Patient Assistance Form is a document that provides financial assistance for people who cannot afford to pay for their medications. This form can be used by patients, doctors, or pharmacists to request medication discounts and other patient assistance from Novartis. The form requires some personal information as well as information about the patient's insurance and financial status. There are several ways to obtain the Novartis Patient Assistance Form. It can be downloaded from the Novartis website, requested by phone, or picked up at a local pharmacy. Patients should always discuss their eligibility for assistance with their doctor or pharmacist before filling out this form.
The table contains information regarding the novartis patient assistance form. You might want to study it just before writing the gaps.
Question | Answer |
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Form Name | Novartis Patient Assistance Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | novartis patient assistance form pdf, pap novartis com, novartis patient assistance application 2021, entresto patient assistance form 2021 |
Information
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 66978, St Louis, MO
Fax:
Dear Patient and Health Care Professional:
Thank you for your interest in the Novartis Patient Assistance Foundation, Inc.
To be eligible for the Novartis Patient Assistance Foundation, Inc. patients must:
Be a U.S. resident
Meet the income requirements and
Have no private or public prescription coverage
The following products are available: |
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AFINITOR® (everolimus) Tablets for |
LAMISIL® Oral Granules (terbinane hydrochloride) |
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Oral Administration |
MYFORTIC® (mycophenolic acid) |
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AFINITOR DISPERZ™ (everolimus) Tablets for |
NEORAL® (cyclosporine) |
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Oral Suspension |
OMNITROPE® (somatropin [rDNA origin] for injection) |
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AMTURNIDE™ (aliskiren, amlodipine and |
RECLAST® |
(zoledronic acid) |
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hydrochlorothiazide) |
SANDIMMUNE® (cyclosporine) |
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ARCAPTA™ NEOHALER™ (indacaterol |
SANDOSTATIN LAR® Depot (octreotide acetate) |
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inhalation powder) |
SIGNIFOR® (Pasireotide) Injection |
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CLOZARIL® (clozapine) |
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TASIGNA® (nilotinib) |
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COARTEM® (artemether and lumefantrine) |
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TEGRETOL® (carbamazepine USP) |
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COSENTYXTM (secukinumab) |
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EXELON® PATCH (rivastigmine transdermal system) |
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TEKAMLOTM (aliskiren and amlodipine) |
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Enoxaparin Sodium |
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TEKTURNA® (aliskiren) |
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EXJADE® (deferasirox) |
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EXTAVIA® (Interferon |
TEKTURNA HCT® (aliskiren and hydrochlorothiazide) |
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FOCALIN® XR (dexmethylphenidate hydrochloride) |
TOBI® (tobramycin inhalation solution USP) |
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GLEEVEC® (imatinib mesylate) |
TOBI®PodhalerTM (tobramycin inhalation powder) |
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GILENYA |
TM |
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TRILEPTAL® (oxcarbazepine) |
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HECORIATM |
(tacrolimus) |
TYZEKA® |
(telbivudine) |
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ILARIS® (canakinumab) |
ZOMETA® |
(zoledronic acid) |
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ZORTRESS® (everolimus) |
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ZYKADIA™ (ceritinib) |
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You may also log onto our web portal, www.npcpapportal.com to ollment application.
What to do:
Step 1 atient Section (page 2)
Step 2 equired
Step 3 our Doctor completes and signs Prescription Section (page 3)
Step 4 ax form with documentation
Patient Section
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
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P.O. Box 66978, St Louis, MO |
Phone: |
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Fax: |
Web: www.npcpapportal.com |
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Patient’s Name: ________________________________________ |
FINANCIAL INFORMATION: Attach a copy of |
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Address: ______________________________________________ |
your household’s most recent year tax returns |
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(1040, 1040EZ, 1099, etc.) |
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City: _____________________________ State: _______________ |
Do not send original documents with your application. |
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Zip: ________________ Phone: ___________________________ |
Total # of People in the home (including self, |
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Cell Phone: ____________________________________________ |
please add all those who are living with you) |
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Email: _________________________________________________ |
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6 or more |
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US Resident: |
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N Gender: M F Veteran: Y |
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# of Children: _______ |
# of Adults: ________ |
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Disabled: Y |
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(Status as deemed by social security) |
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List all sources of Gross Monthly Income: |
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Social Security/ID No: __________________________________ |
Salary/Wages (All Sources): |
$_________________ |
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Date of Birth: _____________ Product:____________________ |
Pension/Retirement: |
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+ $_________________ |
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Patient Advocate Name: ________________________________ |
Social Security: |
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+ $_________________ |
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Disability: |
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+ $_________________ |
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Address: _______________________________________________ |
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Unemployment Bene |
+ $_________________ |
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City: _____________________________ State: ________________ |
Alimony/Child Support: |
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+ $_________________ |
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Zip: ________________ Phone: ____________________________ |
Total Gross Monthly |
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Email: _________________________________________________ |
Household Income |
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= $_________________ |
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PATIENT INSURANCE INFORMATION: Please include a copy of the front and back of your Prescription Card and Insurance Card
Medical Coverage Identication No.
Phone Number |
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Medicare Part A |
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N |
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(_______) |
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Medicare Part B |
Y |
N |
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(_______) |
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Medicare Part D |
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N |
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(_______) |
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Medicaid |
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N |
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(_______) |
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State Elderly Drug Assistance |
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N |
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(_______) |
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State Children Health Insurance |
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N |
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(_______) |
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Veterans Assistance |
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N |
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(_______) |
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Private Insurance |
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N |
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(_______) |
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Other |
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N |
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(_______) |
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Read & Sign Patient Authorization |
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I give permission for my doctor(s) and their sta to |
disclose my personal information, including information about my insurance, prescription, medical condition and |
health (Health Information) to the Novartis Patie |
nt Assistance Foundation, Inc. (the Foundation) so that the Foundation can decide if I am eligible for the Novartis |
Patient Assistance Program (PAP); operate the PAP |
and the Foundation; send me information about PAP and other programs that might help me pay for my medicines; |
send my information to other programs that might help me pay for my medicines; ask me for nancial, insu rance and/or medical information and share my information as required or permitted by law. I give permission to the Foundation to use information on this Application and any other information I give to the Foundation for these same reasons. I also give the Foundation permission to share my Health Information and other information with people and companies that work with the Foundation; government agencies, including the Centers for Medicare and Medicaid Services; insurance companies, including Medicare Part D plans; my doctor(s) and other people, or institutions who are involved in my healthcare, such as pharmacies and hospitals; other organizations that might help me pay for my medication. I promise that any information, including nancial and insurance infor mation that I provide to the Foundation are complete and true and unless I have said something dieren t in this application, I have no drug insurance coverage, which includes Medicaid, Medicare or any public or private assistance programs or any other form of insurance. If my income or health coverage changes, I will call the PAP at
Patient or Legal Guardian Signature: ____________________________________________________________ Date: ________________________
Prescription Section
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 66978, St Louis, MO
Fax:
HEALTH CARE PROFESSIONAL (HCP) INFORMATION: To be completed by the HCP.
HCP Full Name: ____________________________________
Address: __________________________________________
City: ___________________ State: __________Zip:_______
Phone: ___________________________________________
Fax: ______________________________________________
Email: _____________________________________________
DEA/State License # : _____________________________
NPI #: _____________________________________________
Advocate’s Name: _________________________________
Address: __________________________________________
City: ___________________ State: __________ Zip:_______
Phone: ___________________________________________
Fax: ______________________________________________
Email: ______________________________________________
Patient’s Full Name: ________________________________
Patient’s Date of Birth: ______________________________
Please list patient’s allergies: No known
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Please list any other medications the patient is currently taking: None
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Product: ___________________________________________
Strength: _________________ Quantity: _______________
Directions: _________________________________________
Refills: One year or: ______ Date of transplant: _________
(if applicable)
Physician Signature:
______________________ _______________________
Substitutions permitted Date
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Dispensed as written
*Note: If required by your state (ie., NY & DE), please fax an original Prescription blank.
Read & Sign HCP Authorization
My signature below certies that the person listed above is my patient for whom I have prescribed the drug identied above. For the purposes of transmitting this prescription, I authorize Novartis Pharmaceuticals Corporation, and its af- liates, business partners, and agents, to forward as my agent for these limited purposes, this prescription electronical- ly, by facsimile, or by mail to a dispensing pharmacy chosen by the
Prescriber Signature: _________________________________________________________ Date:_____________________
Checklist
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 66978, St Louis, MO
Fax:
Did you:
Fill out the Patient Section?
Sign the bottom of the Patient Section?
Include a copy of your
Have the doctor escription Section?
Have the doctor sign the prescription and form?
If you have checked all the boxes above, you are ready to submit the form!
Follow these steps to complete your application process:
1.Mail pages 2 and 3 of the Application with Financial Documentation to:
NOVARTIS PATIENT ASSISTANCE FOUNDATION, INC. P.O. Box 66978
ST. LOUIS, MO
OR
2.Fax pages 2 and 3 of the Application with a Health Care Professional Fax Cover Sheet and Financial Documentation to:
Fax:
axed, it must be sent from the Health Care Professional’s o
We will review and process your application once we receive the completed application with supporting ou will receive a letter about your status soon.
If you have any questions, please call a Novartis Patient Assistance Foundation, Inc. representative at