Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
 
 
Apligraf Patient Assistance Program

150 Dan Road
Canton, MA 02021
Phone : 888-432-5232 Ext OPT 3
Fax: 866-212-2888
Eligibility
> The patient must have no insurance 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.
 
Apligraf
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader