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Keppra Patient Assistance Program Form

Keppra Patient Assistance Program Form

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What is the Keppra Patient Assistance Program

The Keppra Patient Assistance Program is designed to provide financial support to eligible patients who require Keppra, an anticonvulsant medication used to treat seizures. This program aims to ensure that individuals who may struggle to afford their medication can access it without financial burden. The program is managed by UCB, the pharmaceutical company that produces Keppra, and is intended for patients in the United States who meet specific eligibility criteria.

Eligibility Criteria

To qualify for the Keppra Patient Assistance Program, applicants must meet certain criteria, which typically include:

  • Being a resident of the United States.
  • Having a valid prescription for Keppra from a licensed healthcare provider.
  • Demonstrating financial need, which may involve providing income documentation.
  • Being uninsured or underinsured, meaning that current insurance does not cover the cost of the medication.

Steps to Complete the Keppra Patient Assistance Program

Completing the application for the Keppra Patient Assistance Program involves several key steps:

  1. Obtain the UCB patient assistance form PDF, which can be downloaded from the UCB website.
  2. Fill out the form with accurate personal and financial information.
  3. Attach any required documentation, such as proof of income or a copy of the prescription.
  4. Submit the completed form and documentation via mail or online, depending on the submission options provided by UCB.

Required Documents

When applying for the Keppra Patient Assistance Program, applicants must provide certain documents to support their application. These may include:

  • A completed UCB patient assistance form PDF.
  • Proof of income, such as recent pay stubs or tax returns.
  • A copy of the prescription for Keppra from a healthcare provider.
  • Any additional documentation requested by UCB to verify eligibility.

Form Submission Methods

Applicants can submit the UCB patient assistance form PDF through various methods, ensuring convenience and accessibility. The primary submission options include:

  • Online submission through the UCB website, where users can upload their completed form and documents.
  • Mailing the completed form and documents to the address specified on the form.
  • In-person submission at designated UCB offices or partner locations, if available.

Legal Use of the Keppra Patient Assistance Program

The Keppra Patient Assistance Program is legally compliant with relevant healthcare regulations and guidelines. It is essential for applicants to understand that the program is intended to provide legitimate assistance to those in need. Misrepresentation of information or failure to comply with the program's terms may result in disqualification or legal consequences.

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