Select VL Indication

Bipolar I Disorder

Major Depressive Disorder

Schizophrenia

Date Of Birth (mm/dd/yyyy):
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First Name:

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Last Name:

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Phone:

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Address:

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Patient City:

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State:

Zip:

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Information for the Patient:

The patient attests that he or she is NOT receiving prescription drug coverage under any federal, state or government-funded insurance program. The patient further understands that if at any time he or she begins receiving prescription drug coverage under any federal, state or government-funded prescription insurance program, he or she will no longer be able to use the program.
Patient must agree to continue

Privacy Notice:

AbbVie may collect your personal data through your online and offline interactions with us, including your contact, demographic, and health-related data. We may also collect your online usage data automatically through cookies and similar technologies. We use this information for several purposes, such as to provide you with, administer, and improve our programs, services and products, customize your experiences, and for research and analytics. We retain your personal data for as long as necessary to fulfill these purposes or to comply with our record retention obligations. We do not sell your personal data, but may use and disclose your personal data with marketing and advertising partners to deliver you ads based on your interests inferred from your activity across other unaffiliated sites and services (“online targeted advertising”) and for website analytics. To opt out of the use or disclosure of your personal data for online targeted advertising or for website analytics, go to “Your Privacy Choices” on our website. For more information on the personal data categories we collect, the purposes for their collection, disclosures to third parties, and data retention, visit our Privacy Notice .

Consent to process sensitive personal information:

By submitting this form, the patient consents to the collection, use, and disclosure of their personal health data, as described in the Privacy Notice above and in AbbVie’s Privacy Notice in the “How We May Disclose Personal Data” section. The patients consent is required to process sensitive personal data under certain privacy laws, and they have the right to withdraw their consent by visiting “Your Privacy Choices” on AbbVie’s website.

IMPORTANT INFORMATION:

By submitting this form, you are referring the above patient to ABBVIE CONTIGO patient support program to determine eligibility of available services and resources. Please share this information with your patient.

Copay Program

Select VL Indication