Abbott Patient Assistance Foundation's Application for Medical Need

Ensure all sections of the application are completed.

Attach current proof of income for all in household.

Patient’s signature/date is required on the application.

Prescriber’s signature/date is required on the application.

Provide copy of Medicaid and/or Social Security denial, if applicable.

Provide copy of private insurance denial letter or policy stating nutritional products are not covered, if applicable.

Contact 1-800-222-6885 to confirm program availability for the requested product.

Patient Name: Gender: Male Female Telephone Number:

Patient Address (No PO boxes please): City: State: Zip:

Date of Birth: SSN (Last four digits only): XXX-XX-

Are you enrolled in Medicare? Yes No If YES, check all that apply: Part A Part B Part D

Do you have private insurance coverage for Nutrition Products? Yes No Are you covered by a state Medicaid Program? Yes No

$ Total Monthly Income for your entire household:

Number of people in your household (including yourself): Number in household under 18:

I understand that any assistance in the form of product at no cost is contingent upon my ability to meet the eligibility criteria for the Abbott Patient Assistance Foundation. I certify that the information I have provided is accurate and complete.

I permit the Abbott Patient Assistance Foundation to speak with the following person(s) about my application and/or care and sign any documents related to the Program on my behalf.

Name: Relationship: Phone:

If the product requested is not available, you will be provided with product that most closely meets the ingredient composition of the requested product.

Product: Flavor(s): Administration: Oral Tube

% Caloric Need to be met with Product: Estimated Total Caloric Need of Patient (Daily): Number of servings per day:

Product: Flavor(s): Administration: Oral Tube

% Caloric Need to be met with Product: Estimated Total Caloric Need of Patient (Daily): Number of servings per day:

Primary Diagnosis: Indications for Use:

Please provide both a primary diagnosis and the indications for use that requires the need for nutrition therapy.

Name and Professional Designation of Prescriber: DEA# (if none available, State License Number): SLN Expiration Date:

Shipping Address (No PO boxes please): City: State: Zip:

Mailing Address: City: State: Zip:

Office Contact Person: Telephone Number: Fax Number:

1. Authorization for Release of Health Information: By signing this form, I represent to the Abbott Patient Assistance Foundation that I have obtained all necessary Federal and state authorizations and consents from my patient.

2. Physician/Care Coordinator Verification: I verify that the information provided is current, complete and accurate to the best of my knowledge and certify that I am authorized to receive medications at the shipping location identified in this application.