Copay Support?

The Dalvance Connects® Copay
Assistance Program
may assist eligible patients with
their out-of-pocket costs for
DALVANCE, up to a maximum
benefit of $2000 per calendar year.


Contact Us

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


  

DALVANCE CONNECTS Forms


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
 DALVANCE CONNECTS Copay Assistance Patient Enrollment Form
 DALVANCE CONNECTS Copay Assistance Patient Enrollment Form (Spanish)