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New Patient Application
What do I need to know before applying?
Before starting the AZ&Me application, make sure you have the following:
Information About You (the Patient)
- Name
- Home Address
- Contact Information: Phone Number & Email
- Health Insurance Information
- Household Size
- Adjusted Gross Income
Your adjusted gross household income is the total income for yourself, your spouse, and all dependents in the household. This can be found on your most recent IRS Form 1040, on line 11.
Information About Your Medication
- AstraZeneca Medication Name & Formulation*
- Prescriber's Name
- Prescriber's Office/Facility Name
- Prescriber's Office Address
*For a list of medications available on the AZ&Me Program, click HERE.
Please note: If you live in Alaska or Hawaii, you may still qualify. Click HERE to see the income guidelines for residents in Hawaii and Alaska.
To apply online, choose the option below that best describes you:
If you would like to download an application, click HERE.
To Apply
Questions about Applying?
For more information on what you need before getting started and what to expect after submitting the application, please read Applying to the Program.
You may report side effects related to AstraZeneca products 
.
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