BLH Patient Assistance Program

Patient Assistance Program: Charity Care

Healthcare Provider Attestation Form

The healthcare provider that prescribes and uses a BioLab Holdings product is solely responsible for ensuring the prescription and use comply with all applicable health plan coverage rules. Please complete all sections below (*indicates a required field). By signing this form, the healthcare provider certifies that there will be no billing to a patient or to any third-party health plan for any products provided by BioLab Holdings. The provider attests that he/she has verified eligibility to the program with the patient and has met all eligibility requirements.

Name of Provider Submitting

Site Name and Contact Name

Site Address

Phone

Email of Person Submitting

NPI #

Collaborating MD/DO Name

Collaborating MD/DO NPI #

Patient ID (first letter of first name, first five letters of last name, last two digits of birth year)

Your Signature

Thank you for your submission. Please be on the lookout for an email from caring@biolabholdings.net for next steps.