• Contact us at 1-800-545-6962 Mon-Fri 8am-5pm EST
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 Applications to begin the online application process.

New!
Applications for the Lilly Cares Foundation Patient Assistance Program may now be submitted online through a secure website.
Here's how the online application process works:

  1. A patient and their healthcare provider (HCP) each submit their portion of the application separately. Individuals type information directly in the online application form and then upload (attach electronic copies of) required documents.
  2. Once a patient or their HCP start the application process, Lilly Cares sends an email to the other party (patient or HCP) to request they complete their portion of the application and provide their electronic signature confirming consent.
  3. To submit a Lilly Cares application online, the person starting the application process must provide an accurate email address for both the patient and the HCP who will be completing the application. If the person starting the application process does not know the correct email addresses for both individuals, a paper version of the Lilly Cares application may be submitted and is available for printing from the Resources tab of this website or by calling Lilly Cares at 1-800-545-6962.

To avoid online application-related email communication from The Lilly Cares Foundation being sent to your junk email folder, please include DONOTREPLYLillyCares@LillyCareseservice.com in your approved email sender list settings.

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

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.
Prescription Fax Form templates or refills for a Lilly Cares product:
The healthcare provider may use these optional Prescription Fax form templates when prescribing Forteo®, Humalog® Junior KwikPen®, Humulin® R U-500, Humatrope®, Taltz®, or when ordering refills for a Lilly Cares product.

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.
Taltz Prescription Fax Form when ordering Taltz.

Lilly Cares Fax Refill Order Form when ordering refills (excluding Forteo, Humatrope, Taltz) for enrolled Lilly Cares Patients.