Company Information Allergan Patient Assistance Program – Company Name Allergan Medication Names Alphagan P, Lumigan, Combigan, Restasis Mailing Address P.O. Box 42847, Cincinnati, OH 45242 Phone 1-800-553-6783 Fax 1-513-618-0054 Website Patient can initiate the application process Other Instructions online Application Information - All applications require the doctor’s signature Send completed application Attach of Income to all applications Mail completed form to CECA: The doctor will sign the form 10431 Patterson Ave, We will mail the form back to you to send Richmond, VA 23238 New applications can be faxed or mailed Application valid for: for 1 year Amount received each order: You will receive a 6 month supply Refill and Renewal Information A Renewal application should be done each Renewal application to be done: year Refills to be done: Re-order when you start your last bottle! Automated Refill options: Not Currently Available Commonwealth Eye Care Contact Information Phone: 804-217-6363 Shauna Shirey, COA Email: shauna@commonwealtheye.com Phone: 804-217-6363 Stacy Wright, COA stacy@commonwealtheye.com
Company Information – Allergan Patient Assistance Program Company Name Allergan Medication Names Alphagan P, Lumigan, Combigan, Restasis Mailing Address P.O. Box 42847, Cincinnati, OH 45242 Phone 1-800-553-6783 Fax 1-513-618-0054 Website Other Instructions Patient can initiate the application process online Application Information - All applications require the doctor’s signature Send completed application Attach of Income to all applications Mail completed form to CECA: 10431 Patterson Ave, Richmond, VA 23238 The doctor will sign the form We will mail the form back to you to send New applications can be faxed or mailed Application valid for: for 1 year Amount received each order: You will receive a 6 month supply Refill and Renewal Information Renewal application to be done: A Renewal application should be done each year Refills to be done: Re-order when you start your last bottle! Automated Refill options: Not Currently Available Commonwealth Eye Care Contact Information Shauna Shirey, COA Phone: 804-217-6363 Email: shauna@commonwealtheye.com Stacy Wright, COA Phone: 804-217-6363 stacy@commonwealtheye.com