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Home » Patient Assistant Program

Patient Assistant Program

1. AZ & ME (AstraZeneca Program)
Click here to view the list of medications covered under the AZ & ME program.

2. Novo NorDisk Application (English, Español)


How to Apply

Download and fill out the application

  • Complete the following sections:
    • Part 2: Patient Information
    • Part 3: Patient Certification and Authorization

Gather proof of income

  • Make a copy of one of the following items to show your adjusted gross annual household income:
    • 2 most current paycheck stubs or earning statements for all working members of your household
    • Last year’s federal Individual Income Tax Return (1040)
    • Social Security income, pension, and other income statements
    • W-2 or 1099 forms
    • Unemployment benefit statements

Take the application and proof of income to your health care provider

  • Your health care provider must:
    • Complete the “For Health Care Practitioner” section of the application, including “Order information” (subsection D)
    • Sign and date the application
    • Fax the completed application and proof of income to 1-866-441-4190, or mail them to Novo Nordisk Inc., PO Box 370, Somerville, NJ 08876. Faxes must be sent from your health care provider’s office

Join us on February 1st to learn about Bioidentical Hormone Replacement Therapy

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Click here to learn more or to RSVP

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