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APPLICATION FOR SKYRIZI (risankizumab-rzaa)

APPLICATION FOR SKYRIZI (risankizumab-rzaa). myAbbVie Assist provides free medicine 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 and Shipping Preference o SECTION 2: Patient History, Diagnosis o SECTION 3: Prescription 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 REQUIRED: Please include proof of income for all in household.

patient information to be completed by patient application for skyrizi® (risankizumab-rzaa) d-617927, ap5 ne; 1 n. waukegan rd north chicago, il 60064 phone: 1-800-222-6885 fax: 1-866-250-2803 5 patient information patient name: dob: sex: m f

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