| |
Program Details
FRESENIUS MEDICAL CARE
PhosLo Patient Assistance Program
PhosLo gelcaps
(calcium acetate
)
|
| CONTACT
INFO |
|
| Address: |
c/o RxCrossroads
10350 Ormsby Park Place Suite #500
Louisville, KY 40223 |
| Phone: |
1-877-774-6756 |
Provider Phone: |
|
| Fax: |
1-866-496-8638 |
Website: |
|
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
The PhosLo Patient Assistance Program provides access to PhosLo for ESRD patients who are without prescription drug coverage and meet program income guidelines which are not disclosed.
Patients with Medicare Part D who are in the donut hole may still be eligible for this program. |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security
# requested on form: |
Yes |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
60 days
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 6 months
|
| Refill Policy: |
Physician's office must fill out another application for additional refills.
|
| Other Information: |
|
|
|
Last Updated: 07/15/2010
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
|
|
