| |
Romark Laboratories Patient Assistance Program for Alinia
|
3000 Bayport Drive
Suite 200
Tampa, FL 33607
Phone
:
813-282-8544
Fax:
813-282-1162
|
|
Eligibility
|
| > |
The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor. |
| Who Can Apply
|
| > |
With the patient's permission, anyone concerned can call for an application. |
|
Required
|
| > |
The doctor must fill out a section, sign the application and attach a copy of the DEA or State License number.The patient must fill out a section, sign the application and attach a denial letter from Medicaid. |
|
Supply
|
| > |
|
|
Ship To
|
| > |
Doctor's office |
|
Note
|
| > |
Eligibility determined on a case-by-case basis.
Contact program for Spanish application. |
| |
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.
|
| Alinia Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|