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MYOBLOC Patient Assistance Program
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Phone
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888-461-2255
Ext 3
Fax:
888-343-3275
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Eligibility
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Patients must be uninsured, be at or below 350% of the Federal Poverty Level, have Cervical Dystonia and be a US citizen. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. It can also be completed online or downloaded. |
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Required
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Doctors must complete a section and sign. Patients must complete a section, sign, attach proof of income and attach other requested documentation. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Myobloc (botulinum toxin type B) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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