Program Applications

Tips for using the applications:

  • You will need Adobe Reader to open the applications. Download this free program or the latest version, which is recommended.
  • Click the button in the top right of the application to turn on the Highlight Fields Option which will highlight the fields to be filled out.
  • Use the "tab" key to easily go to the next field.

As of 02/13/2016 there are 667 applications available.

Click on the first letter of the name of the program. Then click on the application for that program. Dates next to each listing reflect the last update. Some applications may need to be opened with a different viewer depending on which browser you are using. Firefox users may get a message saying "This PDF document might not be displayed correctly." Try clicking on the "Open With Different Viewer" option. If you are still unable to interactively complete the application, use a different browser.

Send the completed application to the address on the application and not to NeedyMeds.

If you cannot find an application or are having trouble printing one, contact the program or company.

Contact NeedyMeds if you find any content errors.

For link problems or other technical problems, send an email to webmaster.

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AbbVie Patient Assistance Foundation Application 10/15/15
AbbVie Patient Assistance Foundation Application for Androgel 10/22/15
AbbVie Patient Assistance Foundation Application for Creon 10/22/15
AbbVie Patient Assistance Foundation Application for HUMIRA 01/06/16
AbbVie Patient Assistance Foundation Application for Lupron Depot 10/15/15
AbbVie Patient Assistance Foundation Application for Norvir and Kaletra 10/15/15
AbbVie Patient Assistance Foundation for Marinol: Contact program
AbbVie Patient Assistance Foundation Medicare D Attestation Form 10/22/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form 10/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Kaletra 10/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Norvir 10/15/15
Access 360 Patient Authorization Form (PAF) 11/16/15
Access 360 Patient Authorization Form (PAF) (Spanish) 11/16/15
Access 360 Referral/Statement of Medical Necessity (SMN) for Synagis 11/16/15
Access 360 Request Form 11/16/15
Access 360 Safety & Prescribing Information for Synagis 11/16/15
AccessCubicin Copay Program Enrollment Form 11/09/15
AccessCubicin Patient Assistance Program Form 11/09/15
AccessCubicin Program Enrollment Form 11/09/15
AccessPlus Financial Assistance Brochure 01/18/16
AccessPlus Patient Assistance Program Enrollment Form 01/18/16
AccessPlus Patient Guide 01/18/16
AccessSivextro Program Enrollment Form 11/09/15
AccessZerbaxa Program Enrollment Form 11/09/15
ACT Program Enrollment Form 11/13/15
ACT Program Enrollment Form (Spanish): Contact program
Actavis Patient Assistance Program Application 02/10/16
Actavis Patient Assistance Program Application Instruction Letter & Product List 02/10/16
Actelion Pathways Enrollment Form: Contact program
Acthar Ophthalmology Start Form 10/20/15
Acthar Start Form 10/20/15
Adasuve REMS Program Brochure 09/04/15
Adasuve REMS Program Physician Letter 09/04/15
Addyi Medication Guide 09/21/15
Addyi REMS Patient-Provider Agreement Form 09/21/15
Addyi REMS Prescriber Enrollment Form 09/21/15
Adempas Patient Enrollment and Consent Form 06/18/15
Adempas Prescriber Enrollment and Agreement Form 06/18/15
Afrezza Statement of Medical Necessity 07/15/15
Afrezza Support Program: Contact program
Akorn Patient Assistance Program Application 12/03/15
Akrimax Patient Assistance Program Enrollment Form 02/11/16
Alcon Cares Application 09/08/15
Alexion Complement Foundation: Contact program
Allergan Patient Assistance Program Application 11/11/15
Alpha-1 AATmosphere Program Enrollment Form 11/11/14
AMAG Assist Reimbursement Enrollment Form 10/23/15
American Regent Patient Assistance Program Application 10/30/15
American Regent Patient Assistance Program Request Form 10/30/15
American Regent Reimbursement Brochure 10/30/15
Amgen FIRST STEP Co-Pay Support: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 02/08/16
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 10/01/15
Angiomax Reimbursement and Patient Financial Assistance Program Application 10/09/15
Arbor Gliadel Wafer Patient Assistance Program Application 01/14/16
Arbor Patient Assistance Program Application 10/21/15
ARCH Patient Assistance Program Application Form 02/11/16
ARCH Patient Assistance Program Application Form (Spanish) 02/11/16
Arestin Rx Access Patient Eligibility Form 10/15/15
Ariad PASS Prescription Form 10/26/15
Aristada Patient Enrollment Form 11/03/15
ASSIST Program: Contact program
Assure Patient Assistance Enrollment Form for Rexulti 11/11/15
Assure Patient Enrollment Form for Abilify Maintena 11/11/15
Assure Patient Enrollment Form for Rexulti 11/11/15
Astellas Pharma Support Solutions (XTANDI) Patient Enrollment Form 02/08/16
Astellas Pharma Support Solutions Enrollment Form (CRESEMBA) 02/11/16
Astellas Pharma Support Solutions: Contact program
Astellas Stock Replacement Program For AmBisome: Contact program
Astellas Stock Replacement Program For Lexiscan: Contact program
Astellas Stock Replacement Program For MYCAMINE: Contact program
Atripla Patient Assistance Program Application 01/26/16
Auxilium Copay Savings Program Reimbursement Form 10/30/15
Auxilium Patient Assistance Program Application for Xiaflex 10/30/15
AZ&Me Prescription Savings Program with Med D Application 02/13/16
AZ&Me Prescription Savings Program with out Med D Application 02/13/16
Azilect Patient Assistance Program Application 06/26/15
Azilect Patient Assistance Program Application (Spanish) 06/26/15

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