Novartis Patient Assistance Form PDF Details

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.

Form NameNovartis Patient Assistance Form
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesnovartis patient assistance form pdf, pap novartis com, novartis patient assistance application 2021, entresto patient assistance form 2021

Form Preview Example


Enrollment Application for the Novartis Patient Assistance Foundation, Inc.

P.O. Box 66978, St Louis, MO 63166-6978 Phone: 1-800-277-2254

Fax: 1-855-817-2711 Web:

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:



AFINITOR® (everolimus) Tablets for

LAMISIL® Oral Granules (terbinane hydrochloride)

Oral Administration

MYFORTIC® (mycophenolic acid)

AFINITOR DISPERZ™ (everolimus) Tablets for

NEORAL® (cyclosporine)

Oral Suspension

OMNITROPE® (somatropin [rDNA origin] for injection)

AMTURNIDE™ (aliskiren, amlodipine and


(zoledronic acid)


SANDIMMUNE® (cyclosporine)

ARCAPTA™ NEOHALER™ (indacaterol

SANDOSTATIN LAR® Depot (octreotide acetate)

inhalation powder)

SIGNIFOR® (Pasireotide) Injection

CLOZARIL® (clozapine)

TASIGNA® (nilotinib)

COARTEM® (artemether and lumefantrine)

TEGRETOL® (carbamazepine USP)

COSENTYXTM (secukinumab)

TEGRETOL®-XR (carbamazepine extended-release tabs)

EXELON® PATCH (rivastigmine transdermal system)

TEKAMLOTM (aliskiren and amlodipine)

Enoxaparin Sodium

TEKTURNA® (aliskiren)

EXJADE® (deferasirox)



EXTAVIA® (Interferon beta-1b)

TEKTURNA HCT® (aliskiren and hydrochlorothiazide)

FOCALIN® XR (dexmethylphenidate hydrochloride)

TOBI® (tobramycin inhalation solution USP)

GLEEVEC® (imatinib mesylate)

TOBI®PodhalerTM (tobramycin inhalation powder)




TRILEPTAL® (oxcarbazepine)








ILARIS® (canakinumab)


(zoledronic acid)




ZORTRESS® (everolimus)




ZYKADIA™ (ceritinib)






You may also log onto our web portal, 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.


P.O. Box 66978, St Louis, MO 63166-6978

Phone: 1-800-277-2254






Fax: 1-855-817-2711










Patient’s Name: ________________________________________


Address: ______________________________________________

your household’s most recent year tax returns

(1040, 1040EZ, 1099, etc.)













City: _____________________________ State: _______________

Do not send original documents with your application.





Zip: ________________ Phone: ___________________________

Total # of People in the home (including self,





Cell Phone: ____________________________________________

please add all those who are living with you)

Email: _________________________________________________






6 or more







US Resident:


N Gender: M F Veteran: Y


# of Children: _______

# of Adults: ________











Disabled: Y


(Status as deemed by social security)


List all sources of Gross Monthly Income:



Social Security/ID No: __________________________________

Salary/Wages (All Sources):












Date of Birth: _____________ Product:____________________



+ $_________________











Patient Advocate Name: ________________________________

Social Security:



+ $_________________






+ $_________________



Address: _______________________________________________





Unemployment Bene

+ $_________________









City: _____________________________ State: ________________

Alimony/Child Support:


+ $_________________










Zip: ________________ Phone: ____________________________

Total Gross Monthly















Email: _________________________________________________

Household Income


= $_________________



























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


Medicare Part A




(_______) ____________-____________








Medicare Part B




(_______) ____________-____________








Medicare Part D




(_______) ____________-____________












(_______) ____________-____________








State Elderly Drug Assistance




(_______) ____________-____________








State Children Health Insurance




(_______) ____________-____________








Veterans Assistance




(_______) ____________-____________








Private Insurance




(_______) ____________-____________












(_______) ____________-____________








Read & Sign Patient Authorization


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 1-800-277-2254. I know that the Foundation may change or end the PAP at any time. I know that if I do not sign this form, I will not be able to participate in the PAP, but this will not aect my ability to get medi cal care, seek payment for this care or aect my enro llment or eligibility for insurance. I know that I can cancel this permission at any time by calling the PAP at 1-800-277-2254. If I do, then I will not be able to stay in the PAP. I understand I have the right to receive a copy of this form.

Patient or Legal Guardian Signature: ____________________________________________________________ Date: ________________________

Prescription Section

Enrollment Application for the Novartis Patient Assistance Foundation, Inc.

P.O. Box 66978, St Louis, MO 63166-6978 Phone: 1-800-277-2254

Fax: 1-855-817-2711 Web:


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


Please list any other medications the patient is currently taking: None


Product: ___________________________________________

Strength: _________________ Quantity: _______________

Directions: _________________________________________

Refills: One year or: ______ Date of transplant: _________

(if applicable)

Physician Signature:

______________________ _______________________

Substitutions permitted Date


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 above-named patient. I certify that any medications received from Novartis (as dened above) in connect ion with this application will be used only for the patient named on this form. These medications will not be oered for sale, trade, or barter. Additionally, no claim for reimbursement will be submitted concerning these medications to Medicare, Medicaid, or any third party, nor will any medications be returned for credit. I acknowledge that I have assisted the patient in enrolling in the Novartis PAP exclusively for purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort. I also agree that Novartis has the right to contact the patient directly to conrm receipt of medicati ons, and I under- stand that Novartis may revise, change, or terminate this program at any time. Finally, to the best of my knowledge, the patient listed above meets Novartis’ eligibility criteria for the PAP.

Prescriber Signature: _________________________________________________________ Date:_____________________


Enrollment Application for the Novartis Patient Assistance Foundation, Inc.

P.O. Box 66978, St Louis, MO 63166-6978 Phone: 1-800-277-2254

Fax: 1-855-817-2711 Web:

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:


ST. LOUIS, MO 63166-6978


2.Fax pages 2 and 3 of the Application with a Health Care Professional Fax Cover Sheet and Financial Documentation to:

Fax: 1-855-817-2711

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 1-800-277-2254, Monday through Friday, 9:00 am to 6:00 pm EST.

3026A-13C 0115

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