| Pharmaceutical Company | Forest Pharmaceuticals |
| Program Address | Forest Pharmaceuticals, Inc. Patient Assistance Program 13600 Shoreline Drive St. Louis MO 63045 |
| Toll Free Phone Number | 800-851-0758 |
| Alternate Phone Number | n/a |
| Fax Number | 314-493-7452 |
| Guidelines and Notes | Most current application has 2/00 revision date upper right corner. Application cannot be faxed; it must be mailed. If prescriber doesn't want patient's name on the outside of shipping box, please note this on the application. Also, if the officr adress on the application is not the same as the one on the prescription, attach letterhead or a business card to verify the mailing address on the application. |
| Initiating Enrollment | They will fax form. Licensed Practitioner signing form can be MD, DO, ARNP, CNP or "other" |
| Health Provider's Role | Complete provider part of form and write prescription for 90 days. |
| Patient's Role | SIGNATURE REQUIRED. |
| How Dispensed | Sends medicine to doctor's offic e via UPS-- within a week of getting completed application. |
| Amount Dispensed | They specify a maximum quantity they will ship for each 3 month period for each medication. |
| Refills | Use entirely new application, just like first time and attach 90 day prescription.. |
| Limit | Unspecified -- patient can reapply every 3 months |