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.
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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.