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 12/08/2016 there are 604 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 09/06/16
AbbVie Patient Assistance Foundation Application for Androgel 09/06/16
AbbVie Patient Assistance Foundation Application for Creon 09/06/16
AbbVie Patient Assistance Foundation Application for HUMIRA 09/07/16
AbbVie Patient Assistance Foundation Application for Lupron Depot 09/06/16
AbbVie Patient Assistance Foundation Application for Marinol 09/14/16
AbbVie Patient Assistance Foundation Application for Norvir and Kaletra 09/07/16
AbbVie Patient Assistance Foundation for Technivie: Contact program
AbbVie Patient Assistance Foundation for Viekira Application 10/20/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form 09/06/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form 09/06/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Kaletra 09/07/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Norvir 09/07/16
Access 360 Patient Authorization Form (PAF) Oncology 09/27/16
Access 360 Patient Authorization Form (PAF) Oncology (Spanish) 09/27/16
Access 360 Request Form 09/27/16
AccessPlus Financial Assistance Brochure 11/28/16
AccessPlus Patient Assistance Program Enrollment Form 11/28/16
AccessPlus Patient Guide 11/28/16
AccessZerbaxa Program Enrollment Form 11/01/16
Accredo Patient Assistance Program for Carbaglu: Contact program
Actelion Pathways Enrollment Form: Contact program
Adasuve REMS Program Brochure 10/04/16
Adasuve REMS Program Physician Letter 10/04/16
Addyi REMS Medication Guide 10/19/16
Addyi REMS Patient-Provider Agreement Form 10/19/16
Addyi REMS Prescriber Enrollment Form 10/19/16
Adempas Patient Enrollment and Consent Form 10/21/16
Adempas Prescriber Enrollment and Agreement Form 10/21/16
Akorn Patient Assistance Program Application: Contact program
Akrimax Patient Assistance Program Enrollment Form 11/29/16
Alexion Access Foundation: Contact program
Allergan Patient Assistance Program Application: Eye and Dermatology Medications 10/11/16
Allergan Patient Assistance Program Application: Medications/Devices 11/08/16
Alpha-1 AATmosphere Program: Contact program
American Regent Patient Assistance Program Application 11/29/16
American Regent Patient Assistance Program Request Form 11/29/16
American Regent Reimbursement Brochure 11/29/16
Amgen FIRST STEP Co-Pay Support: Contact program
Amgen Safety Net Foundation: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 10/19/16
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 10/19/16
Angiomax Reimbursement and Patient Financial Assistance Program Application 11/29/16
Aptevo Therapeutics Reimbursement and Patient Assistance Program Application 11/11/16
Arbor Gliadel Wafer Patient Assistance Program Application 10/19/16
Arbor Patient Assistance Program Application 10/19/16
ARCH Patient Assistance Program Application Form 09/05/16
ARCH Patient Assistance Program Application Form (Spanish) 09/05/16
Arestin Rx Access Patient Eligibility Form 10/27/16
Ariad PASS Prescription Form: Contact program
Aristada Care Support Patient Assistance Program Enrollment Form 11/10/16
ASSIST Program: Contact program
Assure for Abilify Tablets Patient Enrollment Form 11/01/16
Assure Patient Enrollment Form for Abilify Maintena 11/01/16
Assure Patient Enrollment Form for Rexulti 11/01/16
Astellas Pharma Support Solutions (XTANDI) Patient Enrollment Form 10/31/16
Astellas Pharma Support Solutions Enrollment Form (CRESEMBA) 10/31/16
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
Auxilium Copay Savings Program Reimbursement Form 11/23/16
Auxilium Patient Assistance Program Application for Xiaflex 11/23/16
Avanir Brochure for Nuedexta 11/11/16
Avanir Brochure for Onzetra Xsail 11/11/16
Avanir Patient Services (APS) Enrollment Form 11/11/16
AZ&Me Prescription Savings Program with Med D Application 06/28/16
AZ&Me Prescription Savings Program with out Med D Application 10/11/16
Azilect Patient Assistance Program Application 10/19/16
Azilect Patient Assistance Program Application (Spanish) 10/19/16

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