Is the online application right for you?
Our online application is for use by the person seeking HUMIRA assistance (the patient). We will ask you to confirm your identity and agree that you have truthfully provided the information requested. We will ask you to electronically sign the application before submitting it. Before you start, please make sure that you have electronic copies of the necessary documents (listed further below).
While you can apply online, we will also need the health care provider who has prescribed your HUMIRA to submit application documents separately. To complete the online application, you can type your information directly in the portal and then upload your supporting documentation. Once you have submitted your application, we will contact your health care provider to obtain your HUMIRA prescription and other needed information.
Our online form will guide you through the steps needed to complete your application:
Step One: Enter your information into our online application and create an account.
Step Two: Electronically sign and date the certifications needed to be considered for enrollment in our program.
Step Three: Upload your supporting documents such as copies of your income documents and insurance card.
Step Four: Submit
We will contact your prescribing doctor for the remaining information. We also will notify you and your health care provider after we have reviewed your application. If you are approved for assistance, we will provide refills based on the prescription from your health care provider.
What documents must be electronically available?
Click here for an optional expense form that can be used to document your prescription and medical expenses.
What if I am not the patient OR I do not have all of my documents available electronically?
Step One: Please access our application here. And print the application.
Step Two : Follow the instructions on the first page to complete the application.
Step Three: Obtain the patient’s signature and date in all needed sections.
Step Four: Gather copies of the supporting documentation to include with the application.
Step Five: Take the application to your health care provider. He or she should complete the page marked ‘PRESCRIBER PRESCRIPTION AND CERTIFICATION ‘ to include signing and dating the form at the bottom.
Step Six: Please fax or mail the completed application and copies of your documents to us. Note that you and your health care provider can send to us separately.
AbbVie Patient Assistance Foundation
D-617927, AP5 NE 1 N. Waukegan Rd.
North Chicago, IL 60064
If you need help at any point during this process, please call us at 1-800-222-6885 Option #4 Monday through Friday 7:00 am to 7:00 pm CSTStart My Application