Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated September 04, 2014


Donnatal Patient Assistance Program

Provided by: Concordia Healthcare USA 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 Program Enrollment Form

Donnatal Patient Assistance Program HIPAA Form

Donnatal Patient Assistance Program Instruction Letter



  • 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/diagnosis
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 section, sign, attach proof of income and other requested documentation
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.