|
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)
|
|
|