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Program Details

Grifols Patient Assistance Program

Alphanate injection (antihemophilic factor/von willebrand factor complex (human))
Address: Grifols PatientCare Program
PO Box 3745
Alhambra, CA 91803-3745
Phone: 1-888-325-8579 - Option 3 Provider Phone:
Fax: 1-323-441-7166 Website: Program Website
Eligibility Info:
  • Patient must not have insurance and must not be eligible for state or federally funded healthcare programs and meet program income guidelines below.
  • Income at or below: Single 250 % FPL
      Couple 250 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    Attachments Required: None
    Physician License #
    Not Required
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Not Published
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Not Published
    Delivery Time: 2-4 weeks
    Re-application Policy: New application every 12 months
    Refill Policy: Physician's office must contact the program.
    Other Information:

    Last Updated: 05/19/2015




    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.

    DocumentForm (English)


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