APPLICATION FOR

AndroGel® (testosterone gel) 1.62%

Please note: This program is open for re-enrollment of people previously approved for assistance only.

myAbbVie Assist provides free medicines to qualifying patients. We review all applications on a case-by-case
basis. Participation in our program is free; we do not collect any fees from people seeking our assistance.

CHECKLIST FOR SUBMITTING AN APPLICATION

 IF YOU ARE THE PRESCRIBER, COMPLETE PAGE 2
o SECTION 1: Prescriber Information
o SECTION 2: Patient History, Diagnosis
o SECTION 3: Prescription-Submit Original Prescription form with application
o SECTION 4: Prescriber Certification and Signature

 IF YOU ARE A PATIENT, COMPLETE PAGE 3. PLEASE READ PAGE 4

o SECTION 5: Patient Information
o SECTION 6: Financial and Medical Information
 Also include proof of income for all in household. A copy of your current federal tax return is preferred.
o SECTION 7: Insurance Information
 If you have Insurance, include front and back copies of all prescription insurance cards.
 If you have insurance coverage, please attach a list of your medical or prescription drug out of pocket
costs. If you are taking multiple prescriptions, a print out from your pharmacy will be helpful. This
information will help us review your eligibility for our program.
o SECTION 8: Patient Consent and Signature
 Carefully read the HIPAA authorization, patient terms of participation and privacy notice in Section 10 on
Page 4.
 Confirm your understanding of our privacy policy by providing your signature and date in Section 8.
o SECTION 9: Additional Permission for Program Purposes (Optional)

 Please keep a copy for your records.

FAX OR MAIL THE COMPLETED APPLICATION AND DOCUMENTATION TO:

myAbbVie Assist Phone: 1-800-222-6885
PO Box 270 Fax: 1-800-276-9901
Somerville, NJ 08876

Upon review of a completed application, we will notify the patient and the prescriber about eligibility.
If approved, we will ship the medication to the patient’s home. Please call 1-800-222-6885 to request refill.
Please contact us at 1-800-222-6885 Monday through Friday for additional assistance.

This program is part of the AbbVie Patient Assistance Foundation, a separate legal entity from AbbVie.

©2020 AbbVie Patient Assistance Foundation A-APP1-20A JAN 2020

 PRESCRIBER PRESCRIPTION AND CERTIFICATION
TO BE COMPLETED BY PRESCRIBER

APPLICATION FOR PO BOX 270

Somerville, NJ 08876
AndroGel® (testosterone gel) 1.62% PHONE: 1-800-222-6885
FAX: 1-800-276-9901
Please note: This program is open for re-enrollment of people previously approved for
assistance only.

1 PRESCRIBER INFORMATION

Prescriber Name: MD DO Other:

Office Name: Office Contact Name:

Address: City/State/Zip:

NPI: Phone: Fax:

DEA: SLN: DEA/ SLN Expiration Date:

For additional information on how AbbVie processes your personal information, please visit www.abbvie.com/privacy.html.

2 PATIENT HISTORY
Patient’s Name: ________________________________________ DOB: _______________

No known allergies Allergies (Please list): ________________________________________________________

Please list the names of other medications the patient is currently taking: None List: __________________________________

3 RX: SUBMIT LICENSED PRESCRIBER’S PRESCRIPTION FORM WITH APPLICATION

 Product will be delivered to patient’s home
 Use Prescriber’s prescription form and submit with application
 Enclose a copy of a government issued ID of the patient when ordering such as: Driver’s license, State
ID, Military ID, etc
Special Note: New York Prescribers please submit prescription on an original NY State prescription blank,
for all other States, please follow State specific requirements for prescribing controlled substances.

PLEASE SUBMIT PRESCRIPTIONS ACCORDING TO YOUR SPECIFIC STATE LAWS, RULES AND REGULATIONS

PRESCRIBER PLEASE SIGN AND DATE ● PRESCIBER MUST MANUALLY SIGN BELOW
4 RUBBER STAMPS, SIGNATURE BY OTHER OFFICE PERSONNEL OR COMPUTER GENERATED IMAGES ARE NOT ALLOWED

PRESCRIBER
SIGNATURE: X____________________________________ X______________________________ DATE: __________
Substitution Permitted Dispense as Written

I verify that the information provided is current, complete and accurate to the best of my knowledge. myAbbVie Assist
reserves the right to request additional information if needed and to change or discontinue the program at any time,
without notice. I shall not seek reimbursement for any medication dispensed hereunder from any government program or
third party, including patient, nor will I sell, trade or distribute any such medication. I also understand that the applicant’s
acceptance into the program should not influence treatment decisions. By signing this form, I authorize program and its
representatives to transmit this prescription form electronically, by facsimile, or by mail to a pharmacy designated by the
program for the dispensing of the medication called for herein. I understand that I may not delegate signature authority. I
certify that treatment with this medication is medically necessary.

©2020 AbbVie Patient Assistance Foundation A-APP1-20A JAN 2020 Page 2 of 4

 PATIENT PLEASE COMPLETE, SIGN AND DATE

APPLICATION FOR PO BOX 270

Somerville, NJ 08876
AndroGel® (testosterone gel) 1.62% PHONE: 1-800-222-6885
Please note: This program is open for re-enrollment of people previously approved for FAX: 1-800-276-9901
assistance only

5 PATIENT INFORMATION
Patient Name: DOB: Sex: M F
SSN (last four digits ONLY): ǀ ǀ ǀ If you do not have an SSN, check here:

Mailing Address: City/State/Zip:

Shipping Address (No P.O. Box): City/State/Zip:
Ok to leave a Ok to leave
Preferred Phone: voicemail Alternate Phone: a voicemail

6 FINANCIAL AND MEDICAL INFORMATION

Attach the most recent copies of proof of income for all

Monthly Total Income for everyone in the household: $ _________
in household. Your most recent tax return is preferred.
Total number of people in your household (including yourself): ____ Number in household over 18 years old with income: ________
_________
MEDICAL INFORMATION
No known allergies Allergies (Please list): _____________________________________________________________
No other medications Other Medications (Please list): ______________________________________________________
7 INSURANCE INFORMATION I have no insurance coverage – go to Section 8
If you have insurance, please provide insurance details below and attach a front and back copy of the insurance
card.
Please include a detailed list of prescriptions such as a Pharmacy print-out and medical expenses for the
household you would like us to consider.
INSURANCE INFORMATION GROUP AND POLICY INSURANCE NAME AND PHONE
Medicare  Yes  No
Medicare Part D  Yes  No
Medicaid  Yes  No
Private Insurance  Yes  No
State Children Health
 Yes  No
Insurance
Veterans Assistance  Yes  No
MEDICARE INFORMATION:

If Yes, please provide your Medicare Part A Identification #: ______________________ Value of your assets: $ ___________
Assets include checking and savings accounts, CD’s, stocks and bonds, savings bonds, mutual funds, IRAs and other investments, cash at home
or anywhere else, and the value of your life insurance policies if turned in for cash right now. Do not include your home, vehicles, burial plots, or
personal possessions.

PATIENT CONSENT PLEASE REVIEW HIPAA AUTHORIZATION, PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE IN
8 SECTION 10 TO UNDERSTAND HOW WE USE YOUR PERSONAL INFORMATION
I acknowledge that I have provided accurate and complete information and understand the Patient Terms of Participation
in Section 10.
My signature below certifies that I have read, understood and agree to the release of my protected health information
pursuant to the HIPAA Authorization in Section 10.
PLEASE
SIGN  x____________________________________________________________X____________________________
PATIENT SIGNATURE / LEGAL REPRESENTATIVE (indicate relationship) DATE

9 ADDITIONAL PERMISSION FOR PURPOSES OF THE PROGRAM (optional)

I permit myAbbVie Assist to speak with the following person about this application:

Name: _________________________________________ Relationship:____________________ Phone Number: ___________________

©2020 AbbVie Patient Assistance Foundation A-APP1-20A JAN 2020 Page 3 of 4

 PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE
PATIENT: PLEASE READ AND SIGN IN SECTION 8

PO BOX 270
APPLICATION FOR Somerville, NJ 08876
AndroGel® (testosterone gel) 1.62% PHONE: 1-800-222-6885

Please note: This program is open for re-enrollment of people previously approved for FAX: 1-800-276-9901
assistance only.

10 HIPAA AUTHORIZATION, PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE

HIPAA AUTHORIZATION Please provide signature in Section 8 on Page 3 of Enrollment Form
I authorize my healthcare providers, pharmacies, insurers, and laboratory testing facilities
(my “Healthcare Companies”) to disclose information about me, my medical condition,
treatment, insurance coverage, and payment information in relation to my use of AbbVie
products, to the AbbVie Patient Assistance Foundation and AbbVie, to enroll me in and
provide me with assistance and support for AbbVie products. I understand that
information released under this Authorization will no longer be protected by HIPAA. I
also understand that if my Healthcare Companies use or disclose my Personal
Information for marketing purposes, they may receive financial remuneration.
I understand that I am not required to sign this Authorization and that my Healthcare
Companies will not condition my treatment, payment, enrollment, or eligibility for benefits
on whether I sign this Authorization. However, I understand that if I do not sign this
Authorization, I cannot take part in myAbbVie Assist (should I qualify). This Authorization
will expire in 10 years or a shorter period if required by state law, unless I cancel it
sooner by calling 1-800-222-6885 or by writing to myAbbVie Assist, PO BOX 270,
Somerville, NJ 08876. I understand that cancelling my Authorization will not affect any
use of my information that occurred before my request was processed.
PATIENT TERMS OF PARTICIPATION
myAbbVie Assist provides free medicines to qualifying patients. Participation in our program is free; we do not collect any
fees from people seeking our assistance. Medication assistance is dependent on your ability to meet the eligibility criteria for
the program as determined by myAbbVie Assist. myAbbVie Assist does not have any obligation to provide the program
services to you and is not liable in the provision of these services. The program may be changed or discontinued without
notice. You will not seek reimbursement for any products dispensed under the program. You will notify the program if your
insurance or financial situation changes. If this application has been completed by a personal representative, the personal
representative will provide a copy of this completed application to you.
If you are a member of a Medicare plan including a Medicare Prescription Drug Plan and are qualified for program assistance,
you will: (i) be eligible to obtain the medication from the program for a calendar year term (ii) not purchase this medication
under your Medicare plan while enrolled in the program; (iii) not submit claims nor seek true out-of-pocket (TrOOP) credit for
the medication provided during your enrollment; (iv) provide written notification to your Medicare Prescription Drug Plan, if
applicable that you are receiving your medication at no cost outside of the Medicare Part D benefit.
If you have questions, want to update your information, or terminate your enrollment, please call 1-800-222-6885 or write to
us at PO BOX 270, Somerville, NJ 08876.

PATIENT PRIVACY NOTICE

myAbbVie Assist will use and disclose with authorized third parties your personal information including your financial and health
information collected on this enrollment form and through participation in the program for the following purposes:
(1) To determine your eligibility for the program and to provide you with related services, including transfer to a separate private or
public payer program, reimbursement services, services to ship your medication, and other support services.
(2) To perform research and data analytics to develop and evaluate products, services, materials, and treatments.
(3) To administer and maintain the quality of the program, including but not limited to case review, compliance checks, audit
review and accounting purposes.

For additional information on how AbbVie processes your personal information, please visit www.abbvie.com/privacy.html.

©2020 AbbVie Patient Assistance Foundation A-APP1-20A JAN 2020 Page 4 of 4