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It explains that eligible patients receive free Lilly medications through their physicians or other authorized prescribers, excluding those with private, public, or government prescription assistance including Medicare. The form includes prescriber and patient sections, shipment and refill timelines, and required attestations, signature and licensing statements, plus patient identity, income documentation, insurance eligibility questions, and authorization to collect and use applicant information.",{"@graph":63,"@context":118},[64,80,101],{"@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/lilly-cares-patient-assistance-program-application-step-one-prescriber-complete-and-step-two-patient-complete/306845/",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/lilly-cares-patient-assistance-program-application-step-one-prescriber-complete-and-step-two-patient-complete/306845.png","ImageObject",442,249,{"name":88,"@type":89},"WPS_1786070896","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the Lilly Cares Patient Assistance Program and who operates it?","Question",{"text":108,"@type":109},"Lilly Cares is a patient assistance program operated and administered by Lilly Cares Foundation, Inc., created, funded, and supplied by Eli Lilly and Company.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does medication delivery work once a patient enrolls?",{"text":113,"@type":109},"If the patient is enrolled, most medications are delivered to the prescriber, and the prescriber dispenses to the patient. Medications usually arrive at the prescriber’s office about 4 weeks after Lilly Cares receives a completed application.",{"name":115,"@type":106,"acceptedAnswer":116},"What documents are required for the patient application and what happens if they are missing?",{"text":117,"@type":109},"A copy of the first page of the most recent income tax return or other proof of income, including any income source, must be included. Failure to include required proof results in rejection and return of the application.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306845,1790229013,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Lilly Cares  \nPatient Assistance  \nProgram  \nPO Box 230999 Centreville VA 20120 1-800-545-6962  \nLilly Cares is a patient assistance program operated and administered by Lilly Cares Foundation, Inc. , a tax-exempt operating foundation created, funded, and supplied by Eli Lilly and Company. Lilly Cares provides free Lilly medications to eligible patients through the patients’physicians or other authorized prescribers. A patient may not participate in the Lilly Cares program if the patient has private, public, or government prescription assistance, including Medicare.  \n• To apply, the prescriber and patient must complete and sign this application.  \n• If the patient is enrolled, most medications are delivered to the prescriber and the prescriber dispenses to the patient.  \n• Medications usually arrive at the prescriber’s office 4 weeks after Lilly Cares receives a completed application.  \n• Patients enroll for a 12-month period and must re-apply annually.  \n• The prescriber’s office requests refills by faxing the Fax Refill Request Form to Lilly Cares (enclosed with each shipment) .  \n¾ Step One: Prescriber-Complete section below (please print clearly)  \nPrescriber’s Name:   \n(circle: M. D. D.O. N. P. P.A. )  \nMailing Address: Street:  City:  State: Zip:   \nShipping Address: Street:  City:  State: Zip: (IF DIFFERENT FROM MAILING ADDRESS) (DO NOT USE PO BOX)  \nPhone:(  )  Fax:    \nMedication Information: (Prescriber to complete)  \nPatient Name:   \nProduct Requested:  Dosage:  Sig:   \nQuantity:  A 4-month supply of most products will be provided unless a lesser amount is requested.  \nHealthcare Provider’s Attestations and Agreement to Participate in Program:  \nLilly Cares agrees, to the extent consistent with its exempt purposes, qualified under Section 170(e)(3) of the Internal Revenue Code of 1986, as amended (the “Code”), and authorized by Lilly Cares policies, to provide medicines, prescription drugs, and other pharmaceutical products, medical supplies, and property (the “Medications”) to the prescriber (the “Healthcare provider”) for the sole purpose of caring for the ill, needy, indigent, and/or infants in the United States (the “Qualifying Patients”) . The Healthcare provider agrees to accept the Medications from Lilly Cares and deliver the Medications only to Qualifying Patients at no charge of any kind and further agrees not to use any of the Medications for any other purpose. The Healthcare provider agrees to provide Lilly Cares ninety (90) days advance notice of any proposed assignment, in full or part, of this agreement. .  \nMy signature immediately below attests to my understanding and agreement to the above Program requirements. I further attest that I am licensed in the state in which I am prescribing, receiving, storing, and dispensing this Medication to the above patient. I further attest that if Medications are received from Lilly Cares as a result of this application, I will accept such Medications and Medications will only be provided to the patient named on this form at no charge. I further attest that this Medication will not be offered for sale, trade, or barter,. I understand that Lilly Cares has the right to contact the patient directly to confirm receipt of the Medications, and to revise or terminate the Program at any time. I further attest that all Medications previously received from Lilly Cares and distributed by me were distributed only to Qualifying Patients.  \nPrescriber Signature:   \nOriginal Signature Only; No Photocopies or Stamps  \nDate:___________ /__________ /_____________  \nState of license:____________________________________________________________________________________  \nState License \\#____________________________________________________________________________________  \nLicense expiration date: _____________________________________________________________________________  \nPage 1 of 2  \nLGO-LC-042009  \n¾ Step Two: Patient– Complete sections below (please print clearly)  \nLilly Cares ","cbCaid5zVaIzzjru","https://ap.wps.com/l/cbCaid5zVaIzzjru","pdf",53178,"English","# Lilly Cares Patient Assistance Program\n## Step One: Prescriber-Complete\n## Step Two: Patient-Complete\n## Patient’s Authorization and Certification","[{\"question\":\"What is the Lilly Cares Patient Assistance Program and who operates it?\",\"answer\":\"Lilly Cares is a patient assistance program operated and administered by Lilly Cares Foundation, Inc., created, funded, and supplied by Eli Lilly and Company.\"},{\"question\":\"How does medication delivery work once a patient enrolls?\",\"answer\":\"If the patient is enrolled, most medications are delivered to the prescriber, and the prescriber dispenses to the patient. Medications usually arrive at the prescriber’s office about 4 weeks after Lilly Cares receives a completed application.\"},{\"question\":\"What documents are required for the patient application and what happens if they are missing?\",\"answer\":\"A copy of the first page of the most recent income tax return or other proof of income, including any income source, must be included. Failure to include required proof results in rejection and return of the application.\"}]","Lilly Cares Patient Assistance Program Application - Step One Prescriber Complete and Step Two Patient Complete | PDF",1789841764]