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Celgene
Resources for Your Practice

Forms and Documents

Did you know that 4 out of 5 patients who requested assistance from Celgene Patient Support® received their medication?

The forms you may need when seeking assistance are provided below. Before getting started, please contact us at 1-800-931-8691. Your dedicated Celgene Patient Support® Specialist will assist you in determining which forms you need and ensure that all the information is completed correctly.

These forms are provided in PDF format. Click on the form to download a PDF. You can type in the form, print it out and sign it. Or, you may print out the form and write in it. To download these forms, you must have Adobe® Reader® on your computer. If you do not have this program, click here to download it for free.

Patient Assistance Application

Your Celgene Patient Support® Specialist may ask you and your patient to complete the Patient Assistance Application if:

  • Your patient is applying for the Celgene free medication program (Patient Assistance Program or PAP), or
  • You need assistance initiating an appeal

The Patient Assistance Application has two parts: one for your patient to complete, and one to be completed by your office. Your Celgene Patient Support® Specialist can guide you and your patient in completing this form. Call us if you need further assistance at 1-800-931-8691.
Download now

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Appointment of Representative Release Form

The Appointment of Representative Release Form is needed so that Celgene Patient Support® may act on behalf of your patient in assisting with appeal support after insurance denial. Your Celgene Patient Support® Specialist can help guide your patient in completing the Appointment of Representative Release Form. Call us at 1-800-931-8691 for further assistance.
Download now

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Medicare Low-Income Subsidy ("Extra Help") Form

Your Celgene Patient Support® Specialist may ask your patient to complete the Medicare Low-Income Subsidy ("Extra Help") Form to see if he/she financially qualifies for a Medicare Low-Income Subsidy. The low-income subsidy provides extra help to qualified patients in paying for their prescription drug costs. Your Celgene Patient Support® Specialist can guide your patient in completing this form. Call us at 1-800-931-8691.

*Your patient may complete this form on the Medicare website. Click here to access this form.

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Your Celgene Patient Support® Specialist is a dedicated, central point of contact who will work with you to resolve access issues to Celgene medications. Contact us at 1-800-931-8691 for assistance.

Need further assistance?

Contact us at 1-800-931-8691 or send us an e-mail.

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Payment Assistance

Discover co-pay assistance opportunities and additional resources

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Help with Appeals

Learn how Celgene Patient Support® can assist you throughout the appeals process

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