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Viatris Patient Assistance Program (PAP) Application

Viatris and the Viatris Globe logo are trademarks of Mylan Inc., a Viatris Company. 2021 Viatris Inc. All rights reserved. Viatris Patient Assistance Program (PAP) Application | Phone: 888-417-5780 | Fax: 877-427-7290 | M-F, 8AM to 5PM EST | Please complete Application in full, sign and date, then fax to: 877-427-7290 Or email to: The PAP Application must be complete to be reviewed for Patient Program eligibility. Please ensure all areas of the form are completed in full, including all signatures. To be considered for the Viatris Patient Assistance Program , all applicants must satisfy the following requirements and eligibility criteria: o Applicants qualify for the Program financial requirements. o Applicants must be a current United States resident (includes Territories).

By signing this Patient Assistance Program Application, I authorize the release of medical and/or other patient information to agents and service providers of Viatris to use and disclose as necessary for verification of patient eligibility, and to furnish any information on this form to the insurer of the applicant for

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Viatris Patient Assistance Program (PAP) Application

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Please ensure all areas of the form are completed in full, including all signatures. ... Prescriber Shipping Information (Only complete if shipping address is different than address listed above) ... the duration of the enrollment period so long as I have a legally valid prescription for my Prescribed Product. I understand that I am not ...

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