| CONTACT
INFO |
|
| Address: |
610 Crescent Executive Court Suite 200
Lake Mary, FL 32746 |
| Phone: |
1-866-801-5657 |
Provider Phone: |
|
| Fax: |
1-866-734-7353 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Be a U.S. resident and have no healthcare insurance coverage for the requested product.
Patient must not have access to alternative sources of coverage or funding.
Patient must meet program income guidelines which are not disclosed.
Require 100% of their caloric needs from the requested product.
|
| |
Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
|
| Shipped To: |
Varies
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|