Program Contact Info / Application Submission
Program	Serostim Patient Assistance Program
Company	ECR Pharmaceuticals
Phone	800-714-2437
Fax	800-214-8698
Program Requirements
Details	Insurance card required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer accepted 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
Delivery of Medication
Delivery Options	Can be delivered directly to the patient Delivery directly to the doctor will be considered on a case by case basis
Application Process
New Applications	New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail
Re-Applications	Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted
Eligibility
Limitations	Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients may be eligible if the medication is not covered under Medicare on a case by case basis Patients are NOT eligible if Medicare coverage has been exhausted
Other Medications
Other  Medications  available in  this program	Serostim 4mg vial - HIV/AIDS Human Growth Hormone (Generic: somatropin) Serostim 5mg vial - (Generic: ) Serostim 6mg vial - (Generic: )