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Updated February 03, 2014
Donnatal

Donnatal Patient Assistance Program

Provided by: PBM Pharmaceuticals, Inc.

301 N Main St
Gordonsville, VA 22942

TEL: 800-858-4006


ALT PHONE:
FAX: 877-811-6709
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Donnatal Patient Assistance Instruction Letter

Donnatal Patient Assistance HIPPA Form

Donnatal Patient Assistance Enrollment Form

 

Medications

  • 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
   

Application

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
   

Medication

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.