We are pleased to introduce the RADIESSE® Patient Access Program. BioForm Medical is committed to helping people with HIV associated Facial Lipoatrophy benefit from RADIESSE treatment. To help fulfill this commitment, we have developed the RADIESSE Patient Access Program, which provides broad access for those patients who qualify for assistance.
WHO IS ELIGIBLE?
In order to qualify for the program, the patient must:
- Have Facial Lipoatrophy associated with HIV
- Lack private or public prescription or healthcare coverage
for RADIESSE dermal filler such as HMO or PPO
- Earn less than $80,000 per year
- Be a U.S. Citizen
- Be at least 18 years old
HOW DOES THE RADIESSE PATIENT ACCESS PROGRAM WORK?
- Licensed physicians practicing in the U.S. who have completed RADIESSE filler training, (and who have acknowledged receipt of materials regarding product use) may apply for the RADIESSE Patient Access Program on behalf of their patients.
- The physician completes the two-page application form providing practice and patient information. The physician signs page one (practice information); the patient signs page two (patient information). Please note that both physician and patient signatures verify that the product is for use consistent with the FDA-approved product indication.
- The physician obtains a photocopy of the patient’s most recent Federal Income Tax Return (or other proof of annual income if the patient does not file).
- The physician sends the Application Form and Proof of Annual Income (i.e., Federal Income Tax Return) to BioForm Medical.
- The physician will be notified in writing (fax or email) within 5 working days that the application has been approved, denied, or needs additional information.
- In accordance with the program rules, after the application has been approved, RADIESSE dermal filler will be shipped to the physician within approximately 2 weeks from receipt of completed application; the physician will be billed at the approved Patient Access Program price. Up to six 1.3cc syringes per year per patient are available under the RADIESSE Patient Access Program.
- Reapplication and approval is required after one (1) year for additional requests.
Send completed application to:
Address: RADIESSE Patient Access Program, BioForm Medical
4133 Courtney Road, Suite 10
Franksville, WI 53126
Click here to download the application.
Your partnership is critical in insuring treatment access, and we appreciate your participation in this important RADIESSE program. For the RADIESSE Patient Access Program application, please contact our Patient Access Program specialist at 866.862.1211.
Please Note : While BioForm Medical will make every effort to provide access to the RADIESSE Patient Access Program for eligible patients, the program is limited to available resources and may be discontinued or revised at any time without further notice. Also be sure to explore how your medical insurance may defer some of the RADIESSE filler cost.
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