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Prescribing Information


Phone Number 1-855-387-2824
Fax Number 1-855-888-7206

Monday through Friday
8 am to 8 pm ET


Program Forms

DALVANCE CONNECTS can assist you with contacting a patient's insurance company to determine coverage and benefits for treatment with DALVANCE. Registered healthcare users can enroll patients via the DALVANCE CONNECTS Provider Portal.
Unregistered healthcare users must complete and fax the enrollment form below to request a benefit investigation, prior authorization research, appeal support, claims assistance, and have patient financial support options researched:

DALVANCE CONNECTS Enrollment Form (pdf)