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Updated February 03, 2014

Donnatal Patient Assistance Program

Provided by: PBM Pharmaceuticals, Inc.

301 N Main St
Gordonsville, VA 22942

TEL: 800-858-4006

FAX: 877-811-6709
Languages Spoken:


Program Website

Patient Assistance Applications

Donnatal Patient Assistance Instruction Letter

Donnatal Patient Assistance HIPPA Form

Donnatal Patient Assistance Enrollment Form



  • Donnatal Tablet dosage varies (Phenobarbital, Hyoscyamine Sulfate, Atropine Sulfate, Scopolamine Hydrobromide)

Eligibility Requirements

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside in the US


Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Mail
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete, sign, attach proof of income and other requested documenation
Decision Communicated Patient and Doctor are notified
Decision Timeframe 5-7 business days


Amount/Supply Varies
Sent To Doctor's office
Delivery Time Within 2-4 business days
Refill Process Good for one year
Limit One year
Re-application New application yearly

Additional Information

Contact program for Spanish application.