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Botox Patient Assistance Program Application Form Template

Streamline the Application Process for Botox Support

It can be challenging to navigate financial assistance for necessary Botox treatments. This template is designed for healthcare providers and patients seeking to simplify the application process for the Botox Patient Assistance Program. With clear, user-friendly fields, WCAG-aligned labels, and a straightforward layout, you can enhance accessibility and ensure eligible patients receive crucial support quickly, reduce processing time, increase approval rates, and improve patient experiences. Explore this live template to get started on improving patient care.

Use this Template (FREE) Live Preview
Who is completing this application?
I am the patient
I am a caregiver or legal guardian
I am a healthcare provider staff
Other
Please Specify:
Patient full name
Date of birth
Email
Phone
Street address
City
State/Province
ZIP/Postal code
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Are you a current U.S. resident?
Yes
No
Primary insurance type
Uninsured
Employer/Commercial
Medicare Part B
Medicare Advantage (Part C)
Medicaid
TRICARE/VA
Marketplace/ACA
Not sure
Other
Please Specify:
Secondary insurance type
None
Employer/Commercial
Medicare Part B
Medicare Advantage (Part C)
Medicaid
TRICARE/VA
Marketplace/ACA
Not sure
Other
Please Specify:
Annual household income before taxes
Household size (including you)
If requested, are you willing to provide proof of income (e.g., recent tax return or pay stubs)?
Yes
No
Primary diagnosis for which BOTOX is prescribed or considered
Please Specify:
Are you currently prescribed BOTOX (onabotulinumtoxinA)?
Yes
No
Have you previously received BOTOX?
Never
Once
2-3 times
4 or more times
Not sure
If known, planned dose per treatment (units)
Planned treatment frequency
Every 12 weeks
Every 16 weeks
Every 24 weeks
One-time treatment
Not sure
Other
Please Specify:
Date of next planned treatment (if known)
Any known allergies to botulinum toxin or product ingredients?
Yes
No
Not sure
Current medical conditions or medications we should be aware of
Are you pregnant, planning to become pregnant, or breastfeeding?
Yes
No
Not applicable
Prefer not to say
Prescriber full name
Practice or clinic name
Prescriber specialty
Please Specify:
Prescriber NPI number
Office phone
Office address (street, city, state, ZIP)
Preferred product delivery location (if eligible)
Prescriber's office
Specialty pharmacy
Hospital/Clinic infusion center
Patient's home (if allowed)
Not sure
Primary insurance member ID
Primary insurance group number (if applicable)
Secondary insurance member ID (if applicable)
Have you applied for manufacturer copay support or a patient assistance program before?
Yes, approved
Yes, denied
Yes, pending
No
Not sure
Do you authorize us to contact your insurer to verify benefits and coverage for BOTOX?
Yes
No
I authorize the program and its service partners to use and disclose my health and insurance information to determine eligibility and coordinate assistance.
Yes
No
I certify that the information provided is accurate and complete to the best of my knowledge and I will report any changes.
Yes
No
Preferred contact methods
Phone
Email
Text message
Mail
Any
Do not contact
Typed signature (patient or legal representative)
Date of signature
Signer relationship to patient
Self
Parent/Guardian
Caregiver
Healthcare provider staff
Other
Please Specify:
{"name":"Who is completing this application?", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Who is completing this application?, Patient full name, Date of birth","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration for Botox Patient Assistance Program application form template with details and design elements.

When to use this form

Use this application when a patient needs help paying for Botox due to no insurance, high deductibles, or coverage denials. Clinics, specialty pharmacies, and patient advocates can use it to collect eligibility details in one secure place: diagnosis, income, household size, and insurance. It streamlines requests for copay support or free drug supply and reduces back-and-forth with the manufacturer. Add consent so you can verify benefits and share records with program partners; if needed, pair it with the GCIC Consent form. Use it during new patient intake, after a prior authorization denial, or when a patient reports financial hardship. The result: faster reviews, fewer errors, and quicker treatment starts.

Must Ask Botox Patient Assistance Program Application Questions

  1. What diagnosis is Botox prescribed for, and who is your prescribing provider?

    This confirms medical necessity and aligns your application with program rules. Including provider details makes it easier to verify records and avoid delays.

  2. What is your current insurance status, including plan name, member ID, and deductible or copay amounts?

    Programs use this to decide if you qualify for copay assistance or free drug. Clear insurance data reduces back-and-forth and speeds benefit checks.

  3. What is your household size and annual gross income?

    Income and household size determine eligibility thresholds in most assistance programs. Accurate numbers help avoid denials or later audits.

  4. Do you consent to share your medical and insurance information with the manufacturer and program partners for eligibility review?

    Explicit consent allows your team to verify coverage, contact your insurer, and submit documentation on your behalf. If you need a separate record, attach the Electronic informed consent form.

  5. Have you received any prior support for Botox, such as copay cards, free drug, or foundation grants?

    This prevents duplicate benefits and ensures compliance with manufacturer and payer rules. It also helps coordinators choose the right pathway for you.

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