ENROLL IN THE BOTOX® SAVINGS PROGRAM

Let's see if you're eligible

Do you have commercial health insurance or commercial prescription drug insurance?

 Yes   No 

Are you enrolled in a federal- or state-funded healthcare or prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of prescription drugs?

 Yes   No 

Are you Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees?

 Yes   No 

Do you receive BOTOX® for an approved medical condition?

 Yes   No 

Which medical condition?

Are you at least 18 years old?

 Yes   No 

Do you receive treatment in the United States or Puerto Rico?

 Yes   No 
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If you are filling out this form for someone else, please provide the information of the person receiving the BOTOX® treatment.

BASIC INFORMATION (*required)




ADDRESS (*required)




PHONE AND OPT-IN (*required)


Text Messaging Opt-In

Sign up to receive notifications regarding my claim status via text message. These messages include claim status updates, reminders to schedule future treatments, and notifications when your reimbursement check has been sent.


I authorize Allergan to send me recurring, automated text messages. I understand that consent to receiving SMS messages is not a condition to participating in the BOTOX® Savings Program or receiving treatment. I also understand that message and data rates may apply and that message frequency depends on each user. I understand I may opt-out at any time by texting STOP and may text HELP for help. Terms & Conditions apply.For T&C. For Privacy Policy

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PRIMARY HEALTH INSURANCE (*required)

In order to help make your future claim reviews quick and easy for you, we need your insurance information to verify your BOTOX® claim information on your behalf. It saves you time and paperwork.



 
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PHYSICIAN SEARCH (*required)

Locate your doctor using the form below.


LOCATION (*either City and state or ZIP code is required)




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TREATMENT DETAILS (*required)

For what medical condition are you receiving BOTOX®

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PASSWORD SETUP (*required)

You will use this email address and password to submit claims and check your BOTOX® Savings Program account.




BOTOX® Savings Program Disclosure

In order for me to participate in Allergan’s BOTOX® Savings Program, I authorize my health care provider and its agents, as well as other health care providers who may have relevant information for my participation in the BOTOX® Savings Program, to release and disclose to Allergan and Allergan’s agents operating the BOTOX® Savings Program, the medical information located in my medical record. This information may include, but is not limited to, my name, address, email address, treatment dates, eligible treatment type and product information, prescription information, including dosage and refill information, and personal information that is used to communicate with me about eligibility, claim status, payment, and other relevant information. My provider may release this information in whatever form and through whatever media the BOTOX® Savings Program requires, including the Internet.

I understand that this information will be used by Allergan and its agents that operate the BOTOX® Savings Program to administer the Program, verify my eligibility, process claims, authorize payments, perform other operational functions, and communicate with me about my use of the BOTOX® Savings Program.

1) I further understand that because Allergan and its agents are not covered by federal privacy regulations, after my information is disclosed to Allergan and/or its agents, it will no longer be protected under federal law and could be subject to re-disclosure. Once disclosed to Allergan and/or its agents pursuant to this authorization, the information will, however, be treated as confidential and will be used and protected by Allergan and/or its agents in accordance with Allergan’s Privacy Statement and Terms of Use, which can be found at: www.allergan.com/privacy.

2) I understand that I may revoke this authorization at any time, but my revocation will not apply to information that has already been released by my health care provider before Allergan receives notice of the revocation. I should send revocations in writing to my health care provider noted in Step 5, or as otherwise directed by my health care provider.

3) I understand that this authorization is voluntary and I may refuse to sign it. While I understand that my refusal to sign this authorization will not affect my ability to obtain treatment or payment for my treatment, by refusing to sign, I may be ineligible to participate in the BOTOX® Savings Program.

4) I will receive a copy of this authorization by submitting a request to my health care provider as noted above. I hereby represent that I am the patient whose name is set forth in Step 1 and that I have all necessary rights and authority to submit this electronic authorization and agree that my medical information may be used and disclosed as set forth above.

5) I understand that by providing and submitting the above data and this consent on this website, I am providing and executing this authorization electronically.

This authorization expires on December 31st following the date this authorization in signed.

By clicking submit, I acknowledge that I understand and agree to the above.

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