0000054431 00000 n In Canada, our AstraZeneca Patient Assistance Program is available to patients in financial need who meet the eligibility requirements for select medications.
0000016173 00000 n 0000114803 00000 n 0000114483 00000 n 0000038291 00000 n AstraZeneca.ca is not responsible for the contents, capabilities or privacy policy of any external websites.We encourage you to read the privacy policy of every wesbite you visit.Click 'cancel' to return to AstraZeneca's site or 'continue' to proceed. 0000113139 00000 n 0000113171 00000 n
0000113651 00000 n For more details about this program or program eligibility, contact our Medical Information Department at 1-800-668-6000 or click below to download our AZCares Canada Program Enrollment Form. 0000035698 00000 n 0000049980 00000 n 0000023239 00000 n AZ&Me™ is designed to help qualifying people without insurance and those on Medicare who are having trouble affording their AstraZeneca medications. %PDF-1.7 %âãÏÓ 0000049238 00000 n 0000114067 00000 n 0000060074 00000 n
0000043860 00000 n 0000100744 00000 n 0000020827 00000 n 0000093715 00000 n 0000038467 00000 n 0000032737 00000 n 0000030265 00000 n 0000112691 00000 n 0000047013 00000 n
0000128497 00000 n 0000031069 00000 n 0000020989 00000 n Fax this completed form to 1-800-268-0774 or email to customer.relations1@astrazeneca.com 0000114931 00000 n 0000048126 00000 n 0000112979 00000 n 0000113267 00000 n 0000043665 00000 n We also have country sites; click the 'Global sites' link for the directory. 0000113587 00000 n 0000051288 00000 n Patient Assistance Program Enrollment and Consent Form ... that coverage is at the discretion of AstraZeneca’s Patient Assistance Program. 0000055374 00000 n 0000115123 00000 n 0000030473 00000 n 0000037358 00000 n 0000111709 00000 n 0000045153 00000 n 0000025812 00000 n 0000049803 00000 n 0000038661 00000 n 0000037553 00000 n 0000033280 00000 n P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions and please retain the HIPAA form for your own records. 0000114195 00000 n 0000034022 00000 n 0000000016 00000 n
0000046641 00000 n 0000033104 00000 n 0000050175 00000 n 0000112467 00000 n 0000074473 00000 n 0000019015 00000 n Patients simply provide their card to a pharmacist along with their prescription at each pharmacy visit.Registered members receive new product updates, can monitor their benefits, and refer friends and family members to the program.For more details about this program, contact our Medical Information Department at 1-800-668-6000 or click below to download our Patient Assistance Drug Request Form.Job loss often means loss of private insurance benefits, including prescription drug coverage; in these unprecedented times, AstraZeneca believes pandemic-related job loss shouldn’t force patients to stop taking their medicines because they can’t afford them.For more details about this program or program eligibility, contact our Medical Information Department at 1-800-668-6000 or click below to download our AZCares Canada Program Enrollment Form.You have selected a link that will take you to an external site.AstraZeneca provides this link as a service to website visitors. 0000032176 00000 n 0000111978 00000 n 0000117955 00000 n CONSENT: I GIVE my doctor, AstraZeneca, and the Program administrator and their employees, agents, and contractors permission to verify my information to make sure it is true and complete; contact me by mail or phone about the Program and about other products, programs, or services that might interest me or for which I may be
0000028865 00000 n 0000049431 00000 n 0000039770 00000 n 0000111858 00000 n 0000077624 00000 n
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