[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306685-105":53,"doc-detail-306685-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","boehringer-cares-patient-assistance-program-application-form","Boehringer Cares Patient Assistance Program Application Form","","Boehringer Cares Patient Assistance Program application form for patients seeking free medicines/products provided by the Boehringer Ingelheim Cares Foundation (BICF). The form lists eligible medications, explains that submission is free, and details eligibility requirements including residency, insurance status, Medicare restrictions, household income guidelines, and limitations for certain alternate-funding programs. It also instructs patients and prescribers on completing sections, signing attestations, and submitting prescriptions and required documentation to verify information.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/boehringer-cares-patient-assistance-program-application-form/306685/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/boehringer-cares-patient-assistance-program-application-form/306685.png","ImageObject",442,249,{"name":88,"@type":89},"Aurelia","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",25,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the Boehringer Cares Patient Assistance Program application used for?","Question",{"text":109,"@type":110},"It is used to apply to the Boehringer Cares Patient Assistance Program to request eligible medicines/products at no charge through BICF.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What are the main eligibility requirements?",{"text":114,"@type":110},"Applicants must be U.S. residents with a physical address, have no health insurance or insurance that does not cover the medication, meet Medicare affordability and Extra-Help constraints, and follow household income guidelines. 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Prescribers should complete applicable information in Sections 6 and 7, read and sign, and submit a prescription, faxing the application to 1-866-851-2827 as instructed.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306685,1790294274,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},1099514068365,"https://ap-avatar.wpscdn.com/avatar/10000253d8d9f28188e?_k=1776742907772140068","Patient Assistance Program Application Form  \nHours: M-F, 8:30 am – 6:00 pm ET  \nPhone: 1-800-556-8317 | Fax: 1-866-851-2827  \nThe Boehringer Cares Patient Assistance Program (the “Program”) is provided by the Boehringer Ingelheim Cares Foundation (“BICF”), an independent nonprofit organization that seeks to help eligible patients receive the following medicines/products for free:  \nAptivus® (tipranavir)  \nAtrovent® HFA (ipratropium bromide HFA)  \nCombivent® Respimat® (ipratropium bromide and albuterol) Cyltezo® (adalimumab-adbm)  \nGilotrif® (afatinib)  \nGlyxambi® (empagliflozin/linagliptin)  \nHernexeos™ (zongertinib) Jardiance® (empagliflozin)  \nJascayd® (nerandomilast)  \nJentadueto® (linagliptin/metformin HCl)  \nJentadueto® XR (linagliptin/metformin HCl extended-release)  \nOfev® (nintedanib)  \nSpiriva® Respimat® (tiotropium bromide)  \nStiolto® Respimat® (tiotropium bromide and olodaterol)  \nStriverdi® Respimat® (olodaterol)  \nSynjardy® (empagliflozin/metformin HCl)  \nSynjardy® XR (empagliflozin/metformin HCl extended-release)  \nTradjenta® (linagliptin)  \nTrijardy® XR (empagliflozin/linagliptin/metformin HCl extended-release)  \nApplying for the Program is FREE. There is no charge for submitting your application form.  \nEligibility  \nAll applications are reviewed in accordance with Program eligibility criteria. To be eligible, you must:  \n• Be a resident with a physical address within the United States or US Territory  \n• Have no health insurance or your insurance does not cover the medication  \n• Have Medicare but cannot afford your medication, and you do not qualify for Medicare’s Extra-Help Program (Low Income Subsidy), except Cyltezo  \n• Not have access to alternate sources of coverage or funding for your medication  \n• Meet household income guidelines established by the Program  \n• Patients with insurance plans or employers participating in an alternate funding program (also sometimes referred to as patient advocacy programs, specialty networks, SHARx, Paydhealth, or PayerMatrix, among other names) requiring them to apply to a manufacturer’s patient assistance program or otherwise pursue specialty drug prescription coverage through an alternate funding vendor as a condition of, requirement for, or prerequisite to coverage of relevant products, or that otherwise denies, restricts, eliminates, delays, alters, or withholds any insurance benefits or coverage contingent upon application to, or denial of eligibility for, specialty drug prescription coverage through the alternate funding program are not eligible for the program. You agree to inform the Program if you are a member of such an insurance plan or if you are applying on behalf of a patient who is a member of such an insurance plan.  \nNote: BICF reserves the right to request additional documentation to verify the information provided in this form for purposes of determining Patient eligibility for assistance, and to conduct periodic audits of Patient’s enrollment. Requested documentation may include items such as Federal Tax Return, W2, 1099, pension statement, Social Security statement, pay stubs, Proof of denial for the Medicare Part D LIS/Extra Help, or other documentation we deem necessary to determine patient eligibility. Missing information in the form, inability to verify information provided and delays in providing requested documentation may result in delays in processing the application and eligibility determinations.  \nApplication Checklists  \nPatient  \n Complete Section 1 – Check which product(s) you are applying for  \n Complete Sections 2-4 – Fill out the Patient Information, Income Information, and Insurance Information  \nNote: Proof of Income documents may be requested for verification purposes.  \n Read and Sign Section 5 – Patient Attestation and Authorization  \nPrescriber  \n Complete all applicable information in Section 6-Prescriber Information  \n Read and Sign Section 7-Prescriber Attestation  \n Submit a prescription to the Program  \n Complete Sectio","cbCaitkoJmg8df6L","https://ap.wps.com/l/cbCaitkoJmg8df6L","pdf",369104,"English","# Eligibility\n## Program overview and free submission\n## Eligibility requirements\n# Application checklist\n## Patient sections 1-5\n## Prescriber sections 6-7 and submission","[{\"question\":\"What is the Boehringer Cares Patient Assistance Program application used for?\",\"answer\":\"It is used to apply to the Boehringer Cares Patient Assistance Program to request eligible medicines/products at no charge through BICF.\"},{\"question\":\"What are the main eligibility requirements?\",\"answer\":\"Applicants must be U.S. residents with a physical address, have no health insurance or insurance that does not cover the medication, meet Medicare affordability and Extra-Help constraints, and follow household income guidelines. Access to certain alternate funding sources can make an applicant ineligible.\"},{\"question\":\"What should patients and prescribers complete before submitting?\",\"answer\":\"Patients should complete Sections 1-4, complete and sign Section 5, and confirm requested income proof if needed. Prescribers should complete applicable information in Sections 6 and 7, read and sign, and submit a prescription, faxing the application to 1-866-851-2827 as instructed.\"}]","Boehringer Cares Patient Assistance Program Application Form | PDF",1789839874]