Step 1
Check to see if you’re eligible for the program or view eligibility requirements.
Step 4
Have your doctor complete their sections of the application, and sign and date in the "HCP Authorization" section (s) for the product (s) they have prescribed.
Step 5
Submit completed page 2 and the pages your HCP has completed for your prescribed product (s) with documentation to:
Next Steps
Once we receive your application, it will take about three days to review. If the application is missing information, it will take longer. Upon completion of review, we’ll send you a letter to let you know whether you’re eligible. When you apply, please be sure to include all your supporting documents.
How to fill out and sign ophthalmi online?
Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:
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