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Resources
Lilly Cares Foundation Patient Assistance Program Applications

Printable Applications:
Lilly Cares Foundation Patient Assistance Program Application
Lilly Cares Foundation Patient Assistance Program Oncology Application

Electronic Applications:

Click here Lilly Cares Foundation Patient Assistance Program Online Application to begin the online application process.


Lilly Cares Refill Authorization Form:

Lilly Cares Fax Refill Form when ordering a refill for enrolled Lilly Cares Patients (excluding Forteo, Humatrope, Olumiant, and Taltz).
Prescription Fax Form template for a Lilly Cares medication:
The healthcare provider may use these optional Prescription Fax form templates when prescribing Emgality, Forteo®, Humalog® Junior KwikPen®, Humatrope®, Humulin® R U-500, Olumiant®, Taltz®, or when ordering refills for these medications.

Emgality Prescription Fax Form when ordering Emgality.
Forteo Prescription Fax Form when ordering Forteo.
Humalog Junior KwikPen Fax Form when ordering Humalog Junior KwikPen.
Humatrope Prescription Fax Form when ordering Humatrope.
Humulin R U-500 Prescription Fax Form when ordering Humulin R U-500.
Olumiant Prescription Fax Form when ordering Olumiant.
Taltz Prescription Fax Form when ordering Taltz.
Lilly Cares Foundation Patient Assistance Program brochure:
If you know someone who may benefit from the Lilly Cares Foundation Patient Assistance Program, this brochure provides our toll-free number and website information.