• Request for services for persons living with Undiagnosed Congenital Disorders, Genetic and Rare Disorders

  • REQUEST FORM

  • The goal of this application is to enable Rare Disease Ghana Initiative process claims for relief services and support for persons living with undiagnosed and rare diseases. 

     

    By filling and submitting this form, I grant Rare Disease Ghana Initiative the permission to use my information to process request for relief services on my behalf or my family under the Patient wellbeing and Care Coordination Program. 

    All information you provide in this application is secured and protected in compliance with the Data Protection Act, 2012 (Act 843) and the data protection policy set out by Rare Disease Ghana Initiative (read full policy here https://www.rarediseaseghana.org/privacy-policy/). 

     

    For  any additional relevant information please contact us via orphan@rarediseaseghana.org /  info@rarediseaseghana.org ; or visit our office at  MVWF+22 Adentan Municipality, Lakeside Estates, Ashale-Botwe, Greater Accra, Ghana.

  • Applicant Information

  • Patient Information

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  • Clinician Information

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  • Medical History

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  • COMMUNITY AND PEER SUPPORT

  • GENETIC TESTING AND OTHER LABORATORY INVESTIGATIONS

  • DRUG AND MEDICATION REQUEST FORM

  • REQUEST FOR ORPHAN DRUGS AND PRODUCTS

     

    Rare Disease Ghana Initiative (RDGI) considers requests for coverage of drug products not listed by the Foods and Drugs Authority (FDA) but have been approved in other jurisdiction and essential for the treatment of chronic, rare and genetic disorders. This form is intended to facilitate requests for drugs under the RDGI’s Therapeutics   Program. RDGI may request additional documentation to support the request.  Please ensure that all appropriate information for each section is provided to avoid delays.

  • Drug Requested

  • DIAGNOSIS AND REASON FOR USE

  • If the patient is currently taking the requested product, please provide start date & objective evidence of its efficacy

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  • Current and / or Previous Medications

  • Clinical Information

  • The collection and use of information on this form is in accordance with the Data Protection Act, 2012 (Act 843) as set out in the RDGI Patient Data Privacy and Confidentiality Agreement. If you have any questions about the collection or use of this information, kindly contact Rare Disease Ghana Initiative at info@rarediseaseghana.org/ orphan@rarediseaseghana.org or call +233 55 271 6011 or contact the Director of Therapeutics Programs, Rare Disease Ghana Initiative, F393/4, Otswe Street, Osu, Accra- Ghana

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