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Program Details

Recordati Reimbursement Hotline

Panhematin Injection (hemin)
Address: PO Box 4280
Gaithersburg, MD 20885
Phone: 1-866-209-7604 Provider Phone:
Fax: 1-866-209-7599 Website: Program Website
Eligibility Info:
  • Patient must meet program guidelines which are not disclosed.
  • Call for prescreening.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Not Published
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Any insurance information
    Physician License #
    Not Published
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: 90 days
    Delivery Time: 0-1 week
    Re-application Policy: New application every 6 months
    Refill Policy: Physician's office must contact program for refills.
    Other Information: Insurance benefits, patient assistance, claims assistance and/or other reimbursement help is available.

    Last Updated: 06/22/2017




    Application Forms
    & Instructions

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


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