Services Request Form

Services Request Form
The goal of this application is to enable Rare Disease Ghana Initiative process claims for products and services intended for use by 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/).

If you have any questions about the collection or use of this information, kindly contact Rare Disease Ghana Initiative via orphan@rarediseaseghana.org / info@rarediseaseghana.org ; or visit our office at MVWF+22 Adentan Municipality, Lakeside Estates, Ashale-Botwe, Greater Accra, Ghana.
I give consent for RDGI to store and share information in this form and other communications with vendors and other professionals working with RDGI for the purposes of understanding cases and other uses related to this patient. *

YES NO

Patient Information
Is the information requested same as the information previously provided above? *

Yes No

Medical History
Summary of patient medical history
Do you or your relative/patient have a confirmed diagnosis of a congenital, genetic or rare disease *

Yes No
If yes, which congenital, genetic or rare disease have you / your relative been diagnosed with?
You should be able to provide some evidence to confirm your diagnosis (this can be a medical records or pictures)
If No, list all symptoms that patient currently experience.
Upload relevant documents supporting your diagnosis or suspicion of a rare, genetic disease. *

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This can be a medical report, a laboratory or radiological investigation or both or pictures of the patient. Cancel of
How many family members are affected by this genetic or rare disorder? *

DRUG AND MEDICATION REQUEST FORM
Type of request
Requested drug product
Drug Identification Number
Strength / Dosage
Frequency of administration
Expected start date
Duration of therapy
Reason for which the drug is requested
Reason for use over formulary alternatives
If the patient is currently taking the requested product, please provide start date & objective evidence of its efficacy
Date

Month Day Year
Date
Supporting documents(test results and/or radiological report

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Cancel of
Details of improvements in clinical symptoms
Please provide details of alternatives (listed drugs and/or non-drug therapy) tried for this condition *
Provide patient’s concomitant drug therapies for other conditions
Authorized prescriber (Full name)

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REQUEST FOR SERVICES AND PRODUCTS