Registered Users Log-in:

E-mail Address:


Forgot Password?
Patient Assistance Information

Grifols Patient Assistance Program (IVIG)

Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803
Phone : (888)325-8579 Ext opt.3
Fax: (323)441-7166
> Must not have any insurance or be eligible for state or federal funded healthcare. Medicare Part D patients are not eligible for this program. Income must be at or below 250% of FPL. Must be citizen or legal resident.
Who Can Apply
> Call to have application faxed, mailed or downloaded from website. Return application via fax or mail. Doctor notified of decision within 5-7 business days.
> Primary Immune Deficiency diagnosis required. Doctor must complete and sign the application and attach a letter of medical necessity Patient must complete and sign application.
> Amount/supply varies. Doctor's office must contact the company for refills. Refill limit not specified. New application must be completed every 12 months.
Ship To
> Ships to Doctor's office, hospital, or pharmacy within 1-3 business days.
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.
Flebogamma DIF
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form Grifols Patient Assistance Program (IVIG)
(Requires Acrobat Reader