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Patient Assistance Information

 
1 Program for Ethyol (amifostine)
 
 
Ethyol Protect Program

PO Box 222197
Charlotte, NC 28222-2197
Phone : 800-887-2467
Fax: 877-675-6513
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 a US resident.
Who Can Apply
> The doctor/doctor's office should call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
>
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an 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.
 
Ethyol (amifostine)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader