How to Fill Out the Botox Patient Assistance Program Application Form

To apply for the BOTOX patient assistance program, download AbbVie’s BOTOX-specific application form from the myAbbVie Assist Available Programs page, complete it together with your prescribing doctor, and fax the signed form to 1-866-217-7178.¹ There is no online application for BOTOX, unlike some other AbbVie medications. If you qualify, the program supplies the medication itself at no cost, shipped directly to the medical facility where your doctor administers it.² Your doctor’s office may still charge a separate injection fee.

Check That You Qualify First

Eligibility turns on three things: where you live, your insurance situation, and your household finances.²

You must live in the United States. The program is designed for people who are uninsured or whose insurance doesn’t adequately cover BOTOX. AbbVie weighs household size, annual income, insurance coverage, and out-of-pocket medical expenses together rather than applying a single income cutoff, so a higher earner with heavy medical bills can still qualify.³

Two situations change the path:

If you have Medicare Part D and your household income is below 150 percent of the Federal Poverty Level, you must first apply for Medicare Extra Help (Low Income Subsidy) and show you were denied before AbbVie will review your application.²
If your insurer or employer routes you through an alternate funding program — names you may see include patient advocacy program, specialty network, SHARx, Paydhealth, or Payer Matrix — you are not eligible. The form asks you to disclose this.⁴

Only FDA-Approved Medical Conditions Count

The program covers BOTOX for therapeutic indications the FDA has approved. Cosmetic use does not qualify. The approved conditions are chronic migraine (15 or more headache days per month, each four hours or longer), cervical dystonia, upper limb spasticity in adults, overactive bladder with urinary incontinence due to a neurologic condition when anticholinergic medication hasn’t worked, severe underarm sweating when topical treatments are inadequate, and blepharospasm or strabismus in patients 12 or older.⁵ Your prescriber confirms the diagnosis and the matching ICD-10 code on the form.

What to Gather Before You Start

Missing documents are the fastest way to delay approval. Before you sit down with the form, have the following ready:

Your Social Security number, if you have one.
Household size (everyone living in your home).
Gross annual household income, before taxes and deductions.
Your insurance plan name, member ID, and a summary of what it does or doesn’t cover for BOTOX.
Proof of income. AbbVie first tries to verify electronically through the credit profile authorization on the form; if that doesn’t work, it asks for your most recent federal tax return, or pay stubs covering at least two pay periods, a Social Security statement, a W-2, or a 1099-R.⁶
Your doctor’s professional name, practice address, phone and fax, National Provider Identifier (NPI), state license number, your diagnosis, and the ICD-10 code.

Filling Out the Form

Download the BOTOX application PDF from AbbVie’s Available Programs page. It’s offered in English and Spanish.¹ The front pages carry the terms of participation, privacy notice, financial disclosures, and HIPAA authorization. The actual enrollment form begins on page four.⁴

Patient Section

Enter your legal name, date of birth, home address, phone, and Social Security number. Fill in household size and gross annual income exactly as they appear on your supporting documents. Add insurance details if you have coverage. By signing, you agree not to seek reimbursement for any BOTOX dispensed through the program and to notify myAbbVie Assist if your insurance or finances change.⁴

Credit Report Authorization

The form includes a required Fair Credit Reporting Act consent that catches many applicants off guard. Signing it lets the program pull information from credit reporting agencies solely to verify your financial eligibility. This is a soft pull used for income verification, not a hard inquiry that affects your credit score. The consent is mandatory. An unsigned authorization will stall your application.⁴

HIPAA Authorization

You also sign a HIPAA authorization letting AbbVie access and share health information needed to run the program, including diagnosis, treatment history, and insurance claims related to BOTOX. AbbVie’s privacy notice states it may collect contact, financial, demographic, insurance, and health-related data and keeps it as long as necessary to administer the program.⁴

Prescriber Section

Your doctor completes a separate section of the same form. They enter their credentials, the practice address where BOTOX will be administered, the diagnosis, and the ICD-10 code, and sign to confirm medical necessity. Both signatures are required. An incomplete form will be returned.

Submitting the Form

Fax the completed, signed form to 1-866-217-7178.⁷ You can also mail it; the mailing address is on the form’s instruction page. Fax is faster and gives you a transmission confirmation. If the patient is under 18, a parent or legal guardian submits the application.⁸

For questions or to check on a pending submission, call myAbbVie Assist at 1-800-442-6869.⁴

After You Apply

AbbVie reviews your financial documents and the credit profile authorization, then notifies both you and your prescribing doctor of the decision. If approved, BOTOX ships directly to the medical facility where your doctor performs the injections, not to your home. Remember the boundary on cost: the program covers only the medication, so your doctor’s office may still bill a separate administration or injection fee each session.

An approved enrollment lasts up to one year. To continue, you re-apply using the same form and the same eligibility criteria. There is no separate renewal document.⁹ If your insurance or finances change during the year, you are required to tell the program, and AbbVie reserves the right to change or discontinue the program without notice.⁴

1
AbbVie. Available Programs
2
AbbVie. Patient Assistance
3
AbbVie. Income Criteria
4
AbbVie. BOTOX Patient Assistance Program Application Form
5
U.S. Food and Drug Administration. BOTOX Prescribing Information
6
AbbVie. Patient Access Support Application Overview
7
RxAssist. AbbVie – myAbbVie Assist for Botox
8
AbbVie. AbbVie Patient Access Support
9
AbbVie. Frequently Asked Questions