Farxiga Patient Assistance Form
The Farxiga Patient Assistance Form is designed to help eligible patients gain access to Farxiga (dapagliflozin), a medication used to manage type 2 diabetes, heart failure, and chronic kidney disease. This form is part of AstraZeneca’s patient assistance program, which offers medications at no cost to qualified individuals.
Key Features of the Farxiga Patient Assistance Form
- Eligibility Criteria: Applicants must meet income requirements and lack prescription drug coverage.
- Required Information: Personal details, healthcare provider information, and proof of income.
- Physician Involvement: The prescribing healthcare provider must complete and sign a portion of the form.
How to Apply
- Obtain the Form: Download the form from the official AstraZeneca Patient Assistance Program website.
- Complete the Form: Fill out all required sections, ensuring accuracy.
- Submit the Form: Send the completed form along with necessary documentation via mail or fax to the address provided on the form.