Form Lgo-Lc - Patient Assistance Program Information Form - Lilly Cares


Lilly Cares
PO Box 230999
Patient Assistance Program
Centreville VA 20120
Lilly Cares is a patient assistance program operated and administered by Lilly Cares Foundation, Inc., a tax-exempt operating foundation
created, funded, and supplied by Eli Lilly and Company. Lilly Cares provides free Lilly medications to eligible patients through the patients’
physicians or other authorized prescribers. A patient may not participate in the Lilly Cares program if the patient has private, public, or
government prescription assistance, including Medicare.
• To apply, the prescriber and patient must complete and sign this application.
• If the patient is enrolled, most medications are delivered to the prescriber and the prescriber dispenses to the patient.
• Medications usually arrive at the prescriber’s office 4 weeks after Lilly Cares receives a completed application.
• Patients enroll for a 12-month period and must re-apply annually.
• The prescriber’s office requests refills by faxing the Fax Refill Request Form to Lilly Cares (enclosed with each shipment).
Step One: Prescriber
- Complete section below (please print clearly)
Prescriber’s Name:____________________________________________________________________________________________
P.A. )
Mailing Address: Street:____________________________________City:______________________State:_________Zip:__________
Shipping Address: Street:____________________________________City:______________________State:_________Zip:__________
Fax: ________________________________________________
(Prescriber to complete)
Medication Information:
Patient Name:______________________________________________________________________________
Product Requested:________________________________________________Dosage:_____________________________
A 4-month supply of most products will be provided unless a lesser amount is requested.
Healthcare Provider’s Attestations and Agreement to Participate in Program:
Lilly Cares agrees, to the extent consistent with its exempt purposes, qualified under Section 170(e)(3) of the Internal Revenue
Code of 1986, as amended (the “Code”), and authorized by Lilly Cares policies, to provide medicines, prescription drugs, and
other pharmaceutical products, medical supplies, and property (the “Medications”) to the prescriber (the “Healthcare provider”) for
the sole purpose of caring for the ill, needy, indigent, and/or infants in the United States (the “Qualifying Patients”). The Healthcare
provider agrees to accept the Medications from Lilly Cares and deliver the Medications only to Qualifying Patients at no charge of
any kind and further agrees not to use any of the Medications for any other purpose. The Healthcare provider agrees to provide
Lilly Cares ninety (90) days advance notice of any proposed assignment, in full or part, of this agreement. .
My signature immediately below attests to my understanding and agreement to the above Program requirements. I further attest
that I am licensed in the state in which I am prescribing, receiving, storing, and dispensing this Medication to the above patient. I
further attest that if Medications are received from Lilly Cares as a result of this application, I will accept such Medications and
Medications will only be provided to the patient named on this form at no charge. I further attest that this Medication will not be
offered for sale, trade, or barter,. I understand that Lilly Cares has the right to contact the patient directly to confirm receipt of the
Medications, and to revise or terminate the Program at any time. I further attest that all Medications previously received from Lilly
Cares and distributed by me were distributed only to Qualifying Patients
Prescriber Signature:________________________________________________________________________________
Original Signature Only; No Photocopies or Stamps
Date:___________ /__________ /_____________
State of license:____________________________________________________________________________________
State License #____________________________________________________________________________________
License expiration date: _____________________________________________________________________________
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