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.

If the online application is not right for you, please download a PDF version to print and complete here.

For more information on creating your application or necessary documents, refer to the Application Overview page.

1 Patient Information
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2 Treating Physician
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3 Household Information
Wages
Social Security Disability Income
Supplemental Security Income
Unemployment
Pension
Other
4 Insurance Information
We need to collect the following to determine eligibility into our program. This information will not be used for any purposes other than verifying your financial coverage.

Once the application is filled out and signed, please upload these supplemental documents:

  • Front and back of your insurance card

  • Detailed list of medical expenses for household, including medications, office visits, insurance premiums, medical bills, etc.

  • Complete the Patient Authorization for Disclosure of Information section

Refer to the Out of Pocket Expense Form here

Primary Insurance

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I am the policyholder
Add Secondary Insurance (Optional) Remove Secondary Insurance

Secondary Insurance

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5 Security Information
Your password must be 8 to 16 characters long and include at least three of the following: uppercase letter, lowercase letter, number, symbol [such as @, #, $].

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Help 1-800-222-6885

DO YOU HAVE ANY QUESTIONS?

Call us at 1-800-222-6885 Option #4 Monday through Friday from 7:00 am to 7:00 pm Central Time.