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

Donnatal

Donnatal Patient Assistance Program

Provided by: Concordia Healthcare USA 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 Program Enrollment Form

Donnatal Patient Assistance Program HIPAA Form

Donnatal Patient Assistance Program Instruction Letter

 

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