rxhelp360.org
| Program Contact Info / Application Submission | ||||||||||||||||||||||||
| Program | Galderma Patient Assistance Program | |||||||||||||||||||||||
| Company | Galderma | |||||||||||||||||||||||
| Form | Download PDF | |||||||||||||||||||||||
| Address | 122 S. Michigan Ave. Suite 1100 Chicago, IL 60603 | |||||||||||||||||||||||
| Phone | 866-730-5074 | |||||||||||||||||||||||
| Fax | 312-935-3599 | |||||||||||||||||||||||
| Website | http://www.galderma.com/ | |||||||||||||||||||||||
| Program Requirements | ||||||||||||||||||||||||
| Details | Proof of Income required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income NOT required as proof of income | |||||||||||||||||||||||
| Other Requirements | Benefits Card good for a 30 day supply of medicine | |||||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||||
| Ship Time | 2 Weeks | |||||||||||||||||||||||
| Delivery Options | Shipped as a voucher card | |||||||||||||||||||||||
| Application Process | ||||||||||||||||||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||||||||||||||||||||
| Appeals | ||||||||||||||||||||||||
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied | |||||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||||
| Other Medications available in this program |
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