Akorn Farmacy counter women and menImportant Steps for Patient and Physician/Prescriber:

  1. Complete ALL information on the application form.
  1. Take the completed application to your physician/prescriber. Both the physician/ prescriber and the patient MUST sign the application.
  1. Have your physician/prescriber write your prescription(s) in Section 2 of the application.
  • A single application may include prescriptions for up to 3 medicines.
  • Each prescription may not exceed a 90-day supply at a time, with a maximum of 3 refills and prescriber must document days supply needed.
  • Each application is valid for up to 12 months; after 1 2 months a new application will be required. Under certain circumstances, enrollment may be limited to a calendar year.
  • A separate Akorn Patient Assistance Program application is REQUIRED for each patient.
  • Prescriber to fax completed applications to: 1-844-500-5254
  • Akorn Patient Assistance Program

Please Note

  • Incomplete or incorrectly completed applications will be returned.
  • Section 2 is your prescription. There is no need to write your prescription on a separate prescription form unless prescriber resides in New York.
  • Patient’s prescription will be sent to the patient’s home address unless otherwise requested by the patient/prescriber in Section 1 of the application.
  • For additional applications or assistance, please call 1-844-202-5909.

PLEASE USE PROVIDED LINK TO ACCESS AND DOWNLOAD THE FORM 

Patient Assistance Program