If you are a patient in need of assistance or know someone in need of assistance, please see the applicant instructions below. If approved, a free 90-day supply of medicine will be sent to the patient's home.

  • Download the application form: Application
  • Complete all the following sections according to the instructions: Patient information, eligibility, signatures, and date
  • Gather proof of income. Examples include a Federal tax return (1040), social security benefit forms (SSA1099), pension interest, retirement benefits, child support, or other sources
  • Give it to your health care professional so he/she can fill out the practitioner and prescribing sections as well as sign and date the application

Once completed, the form and any necessary documents should be submitted to Novo Nordisk by mail or fax:

Return by fax to: 1-888-868-9853

Return by mail to:
Novo Nordisk Patient Assistance Program
Hormone Therapy
PO Box 181640
Louisville, KY 40261

Please call Novo Nordisk at 1-888-868-9852 if you have questions.