The Hepatitis Technologies Compassionate Assistance Program is designed to assist financially disadvantaged individuals. All applications are reviewed on a case-by-case basis. Eligibility is based on current Federal Poverty Guidelines adjusted for household size. The provision of free supplement products is a philanthropic activity sponsored by Hepatitis Technologies. Therefore, the Hepatitis Technologies Compassionate Assistance Program is considered the payor of last resort.
Please complete the entire application. Failure to complete any section or to provide all required documentation will delay the review process. Incomplete applications will be returned for further information.
Client Information Section:
To be completed by the client or legally authorized representative.
Proof of monthly household income is required. You must report all income, including salary, pension, Social Security, etc. for all members in the household. A letter of Medicaid, Social Security, and/or ADAP denial or QMB statement is required, if applicable. Please carefully review the client application and consent form. Client or legally authorized representative's signature and date are required. Please provide documentation of authorization if signing for client. Consent must also be notarized by a notary public.
Product Information Section:
Please check off which products you are applying for under the Hepatitis Technologies Compassionate Assistance Program.
Please ensure that the application is complete. Fax OR mail the original completed application and associated documentation to Hepatitis Technologies for eligibility review.
Approval & Shipment
Upon approval into the Hepatitis Technologies Compassionate Assistance Program, a supply of the product will be shipped directly to the client.
Click here to get the form