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The Sanofi Patient Assistance form serves as a crucial step for individuals seeking access to necessary medications and resources at no cost through the Sanofi Patient Connection program. This program provides select Sanofi prescription medications and vaccines for eligible patients. To qualify, applicants must be U.S. residents under the care of a licensed healthcare provider, meet specific income criteria, and demonstrate lack of insurance coverage or limited access to prescribed treatments. The application process involves completing several sections: personal information, health insurance details, and a patient authorization section. Applicants must submit the form to their healthcare provider for completion and signature before it is sent to Sanofi. Once submitted, applications are reviewed for eligibility. Successful applicants receive medications within a few days, while those who do not qualify are informed of the reason for denial. Understanding and adhering to the application requirements can significantly streamline the process, ensuring timely access to essential health services.

Sanofi Patient Assistance Example

APPLICATION

Sanofi Patient Connection® is a program (the “Program”) to help you get access to the medications and resources you need at no cost. Patient Assistance Connection is part of the Program that provides select Sanofi prescription medications and vaccines, at no cost, if you meet certain eligibility requirements. Patient Assistance Connection is made possible through Sanofi Cares North America.

Who may be eligible for Patient Assistance Connection?

In order to be eligible for this portion of the Program, you must meet the following requirements:

•You must be a resident of the U.S. or the U.S. territories and be under the care of a licensed healthcare provider authorized to prescribe, dispense and administer medicine in the U.S.

•You must have an annual household income of [≤400%] of the current Federal Poverty Level. If you may be eligible for Medicaid, you will be required to provide documentation of Medicaid denial before being assessed for patient assistance eligibility.

•If you are enrolled in Medicare Part D, you may also be eligible based on the income criteria noted above.

•You must have no insurance coverage or, for commercially insured patients, have no access to the prescribed product or treatment via your insurance.

•For Vaccines, you must be 19 years of age or older (except for IMOVAX® Rabies and IMOGAM® Rabies-HT).

How do I apply?

Complete page 2, sign page 3, then bring or send the form to your healthcare provider to complete and sign page 4. Missing information may delay processing of your application. Your completed application may be submitted by your healthcare provider as follows:

U.S. Mail

Fax

Secure Provider Portal*

Sanofi Patient Connection

1.888.847.1797

www.visitspconline.com

PO Box 222138

 

*Excluding Mozobil® and Thymoglobulin®

Charlotte, NC 28222-2138

 

What happens next?

When we receive your application, we will review it to see if you qualify for Patient Assistance Connection. If you are eligible:

1.You and your healthcare provider will receive a letter notifying you of enrollment. If you are a Medicare Part D patient, your plan sponsor will also receive a letter notifying it of your enrollment.

2.You will be enrolled for 12 months. If you are a Medicare Part D patient, you will be enrolled through the end of the calendar year.

3.Your medication will be sent directly to your healthcare provider’s office in approximately 5-7 business days from when you are approved.

If you do not qualify for Patient Assistance Connection, we will send you and your healthcare provider a letter with the reason for denial.

Do not include Patient Medical Records with this application.

© 2021 Sanofi US Services, Inc.

 

P: 1.888.847.4877 · F: 1.888.847.1797

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APPLICATION

1. PATIENT INFORMATION

First Name

Gender

 M  F

Phone

MI

DOB

 

Email Address

Last Name

SSN

 

Primary Language

Address

 

 

 

City

State

 

Zip Code

Household Size

 1  2  3  4  5  Other:

 

Annual Household

 

Income

 

 

 

I permit Sanofi Patient Connection to speak with the following person and/or organization about the information on this application and the status of my application request.

Patient Representative/Organization Name

Relationship to Patient

Phone

2. PATIENT INSURANCE INFORMATION

Insurance?

Yes

No

If yes, is it Medicare Part D?

Yes

No

Primary Insurance

 

 

 

Secondary Insurance

 

 

Policy #

 

 

Group #

Policy #

 

Group #

Policyholder Name

 

 

 

Policyholder Name

 

 

DOB

 

 

 

DOB

 

 

Insurance Phone

 

 

 

Insurance Phone

 

 

3. RESOURCE CONNECTION

Do you want the Program to help identify resources provided by other organizations?

Please note: You will receive a separate call from a Program associate with contact information for helpful resources checked on your application.

If yes, please mark which resources you may be interested in if available:

Yes (PATIENT SIGNATURE FOR AUTHORIZATION IN SECTION 4 REQUIRED)

No

 Clinical Support Services  Transportation Information

 Health Supplies

 Nutritional Supplements (groceries, food banks, etc.)

 Home Care Services (shelter, utilities, etc.)

 Other (Please Elaborate):

 

Do not include Patient Medical Records with this application.

© 2021 Sanofi US Services, Inc.

 

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APPLICATION

4. PATIENT AUTHORIZATION (REQUIRED)

Please read the following carefully, then date and sign where indicated below.

Income Verification: Sanofi Patient Connection and its authorized third party agents will use my date of birth or social security number and/or additional demographic information as needed to access my credit information and information derived from public and other sources to estimate my income in conjunction with the eligibility determination process. As a soft credit inquiry, this option will not impact my credit score . Sanofi Patient Connection and its authorized third party agents reserve the right to ask for additional documents and information at any time.

I state that the information and documents provided in connection with this application are complete and accurate. I agree to immediately inform a Program representative and my Doctor/ Healthcare Provider if my income or insurance status changes during the course of my participation in this Program.

HIPAA Consent: I authorize my healthcare providers and staff; my health insurer, health plan or programs that provide me health benefits (together, “Health Insurers”) to disclose to, Sanofi US, its affiliated companies (i.e. Sanofi Pasteur U.S. and Genzyme, a Sanofi Comp any), Sanofi Cares North America, and authorized third party agents involved in administration of this Program, (collectively “Program Sponsor”), health information about me, including information related to my medical condition, treatment, health insurance coverage, claims, prescriptions and referral to and enrollment in this Program for purposes of determining my participation in, and administering, the Program, which may include contacting me as well as my Doctor/Healthcare Provider, office/hospital staff, insurer (public/private) or others. I understand a representative from Sanofi may contact me for follow-up on any adverse event I may report regarding a Sanofi product. I authorize and consent to release of identifiable information about me including medical, financial and insurance records and information as required for participation in the Program. I understand that identifiable information about me will be kept confidential and will not be further used or disclosed except to administer the Program, or as required by law. I understand that information I authorize to be disclosed may be re-disclosed and is no longer protected by Federal privacy regulations. I agree that this authorization is voluntary and that I may refuse to sign this authorization. Refusal to sign will not affect my ability to obtain treatment but I will not be able to participate in this Program. Unless revoked, this authorization shall remain in effect throughout my participation in the Program, including subsequent reapplication as required. I may withdraw this authorization at any time by written notification to my Doctor/Healthcare Provider; however, withdrawal of authorization will terminate my participation in this Program and will not affect information already disclosed under this Authorization.

I understand that it is my responsibility to follow-up with my prescriber or the Program to make sure that my re-orders, as appropriate, are requested in a timely manner by my Provider so I do not run out of medication. I understand that Sanofi US and Sanofi Cares North America reserve the right at any time and without notice to modify or change eligibility criteria or discontinue this Program.

Patient Authorization (REQUIRED)

By signing below, I acknowledge that I have read and agree to the Patient Authorization to

Use and Disclose Health Information above.

 

Patient/Representative Signature (REQUIRED)

 

Printed Name

Date

5. PATIENT CONSENT

Please read the following carefully, then date and sign where indicated below.

I authorize the Program to contact me by mail, telephone, or e-mail, with information about the Program, disease state and products, promotions, services, and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. I further authorize the Program to de-identify my health information and use it in performing research, including linkage with other de-identified information the Program receives from other sources, education, business analytics, marketing studies, or for other commercial purposes. I understand that entities operating or administering parts of the Program may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services or to send the communications listed above (the “Communications”). I understand and agree that the Program may use my health information for these purposes and may share my health information with my doctors, specialty pharmacies, and insurers. I understand that I may be contacted by the Program in the event that I report an adverse event associated with a Sanofi product.

I understand that I do not have to opt in to receive the Communications, and that I can still receive patient assistance through the Program, as prescribed by my physician. I may opt out of receiving Communications offered by the Program, at any time by notifying a Program representative by telephone at 1-800- 633-1610 or by mailing a letter to Sanofi US Customer Services, P.O. Box 5925 Mailstop 55A-220A5, Bridgewater, NJ 08807-5925. I also understand that the Services may be revised, changed, or terminated at any time.

Patient Consent

By signing below, I acknowledge that I have read and agree to the Patient Consent above.

Patient/Representative Signature

 

Printed Name

Date

Do not include Patient Medical Records with this application.

© 2021 Sanofi US Services, Inc.

 

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APPLICATION

6. TO BE COMPLETED BY THE HEALTHCARE PROVIDER (HCP)

Please check the appropriate box (prescriber and patient signature required for all applications)

Patient Assistance

Benefits Verification (BV) and Patient

 BV only

No cost medication program. Check this

Assistance

Insurance coverage research program.

box if patient does not have health

Insurance coverage research and no cost

Check this box if only insurance coverage

insurance coverage.

medication program. Check this box if the

research is desired.

 

patient has insurance coverage.

 

7. TREATMENT AND PRESCRIBING INFORMATION

Patient Name

 

 

DOB

 

 

Medication #1

 

 

Medication #2

 

 

ICD-10 Code

 

 

ICD-10 Code

 

 

 Vials

 Pens

 N/A

 Vials

 Pens

 N/A

Dosage (# of units per day)

 

Dosage (# of units per day)

 

Qty

 

 

Qty

 

 

8. PRESCRIBER INFORMATION

Prescriber Name

 

 

State Where

 

 

Licensed

 

 

 

License #

NPI #

Tax ID #

DEA #

Facility Name

 

 

 

Facility Address*

 

 

 

City

 

State

Zip Code

Office Contact Name

 

Title/Role

 

Primary Phone

 

Primary Fax

Primary Email

*Sanofi product must be shipped to the signing prescriber’s office or hospital address authorized by the prescriber and not to a 3rd party.

I certify that the information provided is current, complete, and accurate to the best of my knowledge. I certify that the Sanofi product is medically necessary for this patient and that I am authorized under State law to prescribe and dispense the requested medication. I certify that I have obtained from my patient all required written authorization for the release of my patient’s personal identification, medical and insurance information to Sanofi US and/or Sanofi Cares North America and their agents and representatives. I understand that any information provided is for the sole use of the Program to verify my patient’s insurance coverage, to assess, if applicable, patient’s eligibility for participation in the Patient Assistance Program and to otherwise administer the Sanofi Patient Connection Program and related services. I understand that I am under no obligation to prescribe any Sanofi product and that I have not received, nor will I receive, any benefit from Sanofi or their agents or representatives for prescribing a Sanofi product. The facility address noted above in Section 8 is my office or hospital address. My signature certifies that any prescription products received from this Program will be used for the above-named patient only and will not be resold nor offered for sale, trade or barter and will not be returned for credit, nor will payment be sought from any payer, patient or other source for product received from the Program.

Prescriber Signature (REQUIRED – no stamps)

SIGN

HERE

Printed Name

Date

Do not include Patient Medical Records with this application.

© 2021 Sanofi US Services, Inc.

 

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9. PRODUCT SELECTION

•Adacel® (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed)

•Adlyxin® (lixisenatide) injection

•Admelog® (insulin lispro injection) 100 Units/mL

•Apidra® (insulin glulisine injection) 100 Units/mL

•Imogam® Rabies-HT Immune Globulin, [Human] USP, Heat Treated

•Imovax® Rabies Vaccine [Human Diploid Cell]

•Lantus® (insulin glargine injection) 100 Units/mL

•Lovenox® (enoxaparin sodium injection)*1

•Menactra® Meningococcal (Groups A, C, Y and W-135) Polysaccharide Diptheria Toxoid Conjugate Vaccine

•Mozobil® (plerixafor injection)1

APPLICATION

•Multaq® (dronedarone) Tablets*

•Pentacel® Diptheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine

•Priftin® (rifapentine) Tablets

•Soliqua® 100/33 (insulin glargine & lixisenatide) injection 100 Units/mL and 33 mcg/mL

•Tenivac® (tetanus and diphtheria toxoids adsorbed)

•Thymoglobulin® [Anti-Thymocyte Globulin (Rabbit)]*,1

•Toujeo® (insulin glargine injection) 300 Units/mL (1.5 mL or 3.0 mL pens)**

*Please see full U.S. prescribing information, including Black Box warning.

**Regular SoloStar® is packaged as 3 pens per pack 450 units/pen; dials up to 80 units per single injection. Max SoloStar® is packaged as 2 pens per pack 900 units/pen; dials up to 160 units per single injection; Max pen dials in 2-unit increments.

1If applying for Drug Replacement (Lovenox®, Mozobil®, and Thymoglobulin®), a copy of the claim, denial, flow sheet(s) and drug dispensing log (with patient name, date of service, product NDC/Lot #, total dosage) must be submitted.

Full U.S. prescribing information for all Sanofi Patient Connection supported products can be accessed at www.visitspconline.com. Sanofi Patient Connection will provide assistance for any medically appropriate use as described in the prescribing information.

10. WHAT DOES A SUCCESSFUL PATIENT ASSISTANCE CONNECTION APPLICATION LOOK LIKE?

To apply for Patient Assistance Connection all information must be complete and include the following:

Patient Information:

•Complete all relevant information on page 2, and sign and date the Patient Authorization on page 3 (REQUIRED).

Healthcare Provider:

•Ask your Healthcare Provider (HCP) to complete page 4 and sign and date it.

•Ask your HCP to mail, fax, or submit through the Provider Portal your completed application.

Missing information may delay processing of application.

Do not include Patient Medical Records with this application.

11. ADDITIONAL INFORMATION

•Sanofi Patient Connection ships most medications in a 90-day supply.

•A representative from Sanofi may contact you for follow-up on any adverse event you may report regarding a Sanofi product.

12. FORM SUBMISSION OPTIONS

U.S. Mail

Fax

Sanofi Patient Connection

1.888.847.1797

PO Box 222138

 

Charlotte, NC 28222-2138

 

Do not include Patient Medical Records with this application.

© 2021 Sanofi US Services, Inc.

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Secure Provider Portal*

www.visitspconline.com

*Excluding Mozobil® and Thymoglobulin®

P:1.888.847.4877 · F: 1.888.847.1797 P.O. Box 222138 · Charlotte, NC · 28222-2138

Get Sanofi Patient Assistance PDF Form

Form Characteristics

Fact Name Description
Program Purpose Sanofi Patient Connection aims to provide access to select Sanofi prescription medications and vaccines at no cost to eligible patients.
Eligibility Criteria Eligibility requirements include U.S. residency, annual household income less than or equal to 400% of the Federal Poverty Level, and lack of insurance coverage for the prescribed medications.
Age Requirement for Vaccines Patients must be 19 years old or older to qualify for vaccines, with exceptions for IMOVAX® Rabies and IMOGAM® Rabies-HT.
Application Process To apply, complete page 2, sign page 3, and submit the form to a healthcare provider for additional signatures and information.
Processing Timeline Applications are processed swiftly, with medications typically shipped to the healthcare provider's office within 5-7 business days after approval.
Annual Enrollment Period Enrollment lasts for 12 months, with Medicare Part D patients enrolled until the end of the calendar year.
Submission Methods Applications can be submitted via U.S. mail, fax, or a secure Provider Portal for approved healthcare providers.
Documentation Required Applicants may need to provide documentation of Medicaid denial if applicable. Income verification is also part of the application process.
Contact Information Patients can reach Sanofi Patient Connection at 1.888.847.4877 or via fax at 1.888.847.1797 for questions or assistance.
State-Specific Regulations Eligibility and application procedures follow state laws, and applicants should verify regulations that may vary by state.

Guidelines on Utilizing Sanofi Patient Assistance

Filling out the Sanofi Patient Assistance form is a structured process that requires careful attention to detail. After completing this form, it will be submitted for review. If eligible, you will receive assistance to access medications at no cost. Here is a step-by-step guide to effectively fill out the form.

  1. Gather personal information, including your first and last name, date of birth, social security number, and contact details.
  2. Indicate your gender and primary language, and provide your home address along with city, state, and zip code.
  3. Specify your household size and annual household income.
  4. Identify if you authorize Sanofi to communicate with any designated representatives about your information.
  5. Answer questions regarding your insurance status, including whether you have Medicare Part D.
  6. Indicate if you wish to use resources offered by other organizations for additional support.
  7. Read the Patient Authorization carefully, then sign and date where indicated on page 3.
  8. Provide details of your prescribing healthcare provider so they can complete and sign page 4.
  9. Ensure your healthcare provider includes all necessary treatment and prescribing information regarding the medications.
  10. Make sure your prescriber provides their name, license number, and contact information on the form.
  11. Submit the completed form through the specified options: by U.S. Mail, fax, or the Secure Provider Portal.

After submission, your application will be reviewed to determine eligibility. If approved, you and your healthcare provider will receive a confirmation letter, along with details on the medication delivery. If you do not qualify, you will be informed of the reasons for the denial.

What You Should Know About This Form

What is the Sanofi Patient Assistance Connection Program?

The Sanofi Patient Assistance Connection Program aims to help individuals access select Sanofi medications and vaccines at no cost. It helps those who meet specific eligibility criteria. The initiative is made possible through Sanofi Cares North America.

Who qualifies for the Patient Assistance Connection?

Eligibility includes being a U.S. resident under a licensed healthcare provider's care. Your annual household income must be ≤400% of the Federal Poverty Level. If you may qualify for Medicaid, you need to provide documentation of denial before applying. Additionally, if you are enrolled in Medicare Part D, you might also qualify based on the same income criteria. Furthermore, you must lack insurance coverage or, if covered, must not have access to the prescribed medications through your insurance. For vaccinations, you must be at least 19 years old, with specific exceptions for certain rabies vaccines.

How can I apply for assistance?

To apply, complete your portion of the application, which includes pages 2 and 3, then give the form to your healthcare provider to fill out and sign page 4. Incomplete forms can lead to delays in processing. The completed application can then be submitted by your provider via mail, fax, or a secure provider portal.

What happens after submitting my application?

Once the application is received, Sanofi will assess your eligibility for assistance. If you qualify, you and your healthcare provider will be notified via a letter. Your enrollment will last for 12 months, and if applicable, your medication will be sent to your healthcare provider within approximately 5-7 business days of approval. If you do not qualify, a letter explaining the reason for denial will be sent to you and your healthcare provider.

Can I submit medical records with my application?

No, you should not include any patient medical records when submitting your application. The program specifically advises against it to protect patient privacy and to simplify the application process.

What medications and vaccines are included in the program?

The program provides various medications and vaccines, including Adacel®, Adlyxin®, and Lantus®, among others. The specifics of available items can be found on the Sanofi Patient Connection website for those looking for detailed information about each product.

What if I have a change in my income or insurance status?

It is crucial to inform the program representatives and your healthcare provider if there’s a change in your income or insurance coverage during your participation in the program. This information may affect your ongoing eligibility for assistance.

How long will I receive assistance?

If eligible, you will receive medications for a duration of 12 months. However, if you are under Medicare Part D, enrollment extends only until the end of the calendar year. Following that period, you may need to reapply to continue receiving assistance.

How can I contact Sanofi Patient Connection for support?

You can reach out to Sanofi Patient Connection at 1-888-847-4877 for any questions or support regarding your application or the program itself. Additionally, you can access their secure provider portal for further assistance.

Common mistakes

Many individuals encounter challenges when completing the Sanofi Patient Assistance form. One common mistake is not providing all required information upfront. Incomplete applications may lead to unnecessary delays in processing. It's essential to ensure every relevant detail, like personal and income information, is filled out completely.

Another frequent error involves miscalculating household income. Applicants must ensure their annual household income does not exceed 400% of the Federal Poverty Level. If documentation is unavailable, this mistake can prevent eligibility, so verifying income against current guidelines is crucial.

Some individuals skip the Medicare Part D section or fail to provide their insurance details accurately. Whether you have insurance or not, this information is critical for determining eligibility. Being honest and thorough here can impact the overall success of the application.

Additionally, individuals often forget to sign necessary sections, especially the Patient Authorization and Patient Consent pages. These signatures indicate consent for information sharing and are mandatory for processing the application. Missing signatures can result in outright rejection of the application.

Another mistake seen is neglecting to contact the healthcare provider to ensure their section is completed properly. The form requires input from a licensed healthcare provider. Following up can prevent additional delays and ensure that the application reflects accurate medical needs.

Applicants sometimes fail to double-check for any additional documents required for their specific situation. For instance, if applying for assistance and enrolled in Medicaid, proof of denial is necessary. Overlooking these requirements can hinder progress.

Some may submit the application without confirming that the healthcare provider has sent it to Sanofi. An individual might fill out everything correctly but still need to ensure that their provider processes the application through the proper channels.

In certain cases, people might not utilize the available resources for assistance effectively. The application includes a section to identify additional resources that could help, so utilizing this feature is beneficial. Additionally, some applicants overlook the potential for follow-up regarding any adverse events related to their medications.

Lastly, crafting an application with care includes being mindful of who is authorized to speak on the applicant’s behalf. This can often be a neglected detail. Clarifying who may discuss the application status ensures smoother communication and avoids confusion later in the process.

Documents used along the form

The Sanofi Patient Assistance form is an essential starting point for individuals seeking financial help with their medication needs. When applying, several other forms and documents may be required to support the application process. Below is a list of common documents often needed alongside the Sanofi Patient Assistance form.

  • Medicaid Denial Letter: Provides evidence that an applicant has been denied Medicaid benefits, which is necessary for those who may qualify for the Patient Assistance Program.
  • Tax Returns: Often required to verify household income. These documents help determine eligibility based on income thresholds set by the program.
  • Income Verification Letter: A document from an employer or government agency confirming the applicant’s income. This can expedite the determination of eligibility.
  • Insurance Information: Details about existing health insurance must be provided to evaluate whether any coverage options are available for the medications requested.
  • Prescription Information: A copy of the prescription from the healthcare provider, detailing the medication needed. This ensures that specific medications are covered under the assistance program.
  • Patient Consent Form: A separate consent document may be needed to allow Sanofi to communicate with healthcare providers regarding the patient's treatment and status.
  • Public Assistance Documentation: Proof of enrollment in other assistance programs, such as SNAP or TANF, may support income level claims.
  • Healthcare Provider's Prescription Verification: This document confirms that the medication is medically necessary. It must be completed by the prescribing healthcare provider.
  • Authorization for Release of Information: This form allows the program to obtain necessary medical and financial information relevant to the application.
  • Proof of Residency: Documentation that confirms the applicant's current address, which is crucial for eligibility as stated in the program guidelines.

Having these documents ready can streamline the application process, helping to ensure that individuals receive the assistance they need in a timely manner. Thorough preparation can help minimize delays and enhance the chances of a successful outcome.

Similar forms

  • Medication Assistance Programs: Similar to the Sanofi Patient Assistance form, medication assistance programs help patients gain access to prescribed medications at low or no cost. Eligibility requirements often include income limits and a lack of insurance coverage, similar to the criteria specified in the Sanofi form.
  • Pharmaceutical Company Patient Programs: These programs provided by various pharmaceutical companies often mirror the Sanofi Patient Connection, offering free medications to qualifying patients. Applicants are usually required to submit income verification and medical necessity documentation, akin to the application process for the Sanofi program.
  • State-Sponsored Prescription Drug Assistance: Many states offer prescription drug assistance that aligns with the Sanofi Patient Assistance form. Eligibility is typically based on income and residency, designed to help individuals who struggle to afford necessary medications.
  • Nonprofit Health Organization Support: Nonprofit organizations may provide support similar to the Sanofi form, often focusing on specific diseases. They usually require applicants to demonstrate need and submit personal and financial information to access free or discounted medications.
  • Medicaid and Medicare Programs: These government programs aim to assist low-income individuals in obtaining medical care, including medications. Like the Sanofi form, they have specific eligibility criteria based on income and insurance status, with documentation required for enrollment and assistance.

Dos and Don'ts

Things You Should Do:

  • Complete all relevant information on page 2 of the form thoroughly.
  • Sign and date the Patient Authorization on page 3.
  • Ensure your healthcare provider fills out and signs page 4.
  • Submit the completed application through your healthcare provider using U.S. Mail, Fax, or the Secure Provider Portal.

Things You Shouldn't Do:

  • Do not leave any sections of the application incomplete.
  • Do not include any Patient Medical Records with your application.
  • Do not submit your application directly; it must go through your healthcare provider.
  • Do not forget to review your application for accuracy before submission.

Misconceptions

1. The program is only for those with no insurance. Many believe that the Sanofi Patient Assistance Program is strictly for uninsured individuals. In reality, it assists those who may have insurance but lack access to specific treatments through their coverage.

2. Eligibility criteria are overly complicated. Some think the eligibility requirements are too complex to navigate. However, the requirements are clearly outlined and primarily focus on residency, income, and insurance status.

3. Application forms can include medical records. A common misconception is that medical records need to be submitted with the application. The program specifically advises against including any patient medical records.

4. Enrollment guarantees access to any medication. Many people assume that being enrolled in the program means they can receive any Sanofi medication. Eligibility is tied to specific medications listed in the program.

5. Only low-income individuals qualify. While earning less than 400% of the Federal Poverty Level is a requirement, individuals with slightly higher incomes may still qualify if they fulfill other criteria, such as insurance status.

6. Applications take a long time to process. There is a belief that it will take forever to get a response after submitting the application. The program typically processes applications within a short time frame — usually 5-7 business days after approval.

7. Healthcare providers can submit applications in any format. Some think any format is acceptable for submitting the application. However, it must be submitted according to specific guidelines, including mailing, faxing, or submitting via a secure provider portal.

8. Assistance through the program is a one-time deal. Many believe that applying for patient assistance is a one-time opportunity. In fact, patients can reapply, and the program may be extended based on updated eligibility criteria.

9. You cannot opt out of communications. People often feel they must accept all communication from the program. While you can receive patient assistance without opting in, you also have the choice to opt out of marketing communications at any time.

Key takeaways

Key Takeaways for Using the Sanofi Patient Assistance Form

  • Eligibility requires being a U.S. resident with no insurance coverage or specific conditions for the insured.
  • Complete all sections of the application to avoid delays in processing.
  • Documentation may be needed if you are applying under Medicaid criteria.
  • Processing times typically range from 5-7 business days after approval.
  • Do not include patient medical records with your application to ensure compliance.

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