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NOVARTIS PATIENT ASSISTANCE FOUNDATION, INC (NPAF) Patient Consent SIGNATURE REQUIRED FOR PATIENTS APPLYING FOR Patient Assistance Program (PAP) – MANDATORY FOR PROCESSING.
Step 1 – Complete and sign Patient Section (page 2) Step 2 – Attach copies of all required financial documentation Step 3 – Your Doctor completes and signs Prescription Section (page 3) Step 4 – Mail or fax form with documentation. Patient Section. Read & Sign Patient Authorization.
Instructions. To see if you are eligible, you will need to complete Patient Sections 1-5 on the Patient Application: Patient Section 1: Fill out your information completely and accurately. This will allow us to review your case and determine your eligibility for our program.
Complete the patient PANO (Patient Assistance Now Oncology) Service Request Form to find out if you qualify for Novartis Oncology programs that may provide financial support and free trial offers. Your information will be processed in tandem with the information your physician submits on your behalf to finalize the request.
Please complete the following steps to apply for the NPAFP. ) Complete all patient and physician sections of the attached application. ) Attach an original prescription for the requested medication (except Retail Card products). ) Attach a copy of your most recent year federal tax return or financial documentation. Some examples include:
If you are experiencing financial hardship and have limited or no prescription coverage, then you may be eligible to receive Novartis medications for free from the Novartis Patient Assistance Foundation, an independent nonprofit organization. To learn more, call 1-800-277-2254 or visit www.PAP.Novartis.com. IMPORTANT SAFETY INFORMATION.
Many patients find it difficult, confusing and stressful to access their medications. Novartis Patient Assistance is a resource that helps connect patients to their Novartis medications and potential support.
