• 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.

  • REQUEST FOR SERVICES AND PRODUCTS

    Rare Disease Ghana Initiative (RDGI) considers requests for products and services essential for use by persons living with undiagnosed, genetic and rare disorders. RDGI may request additional documentation to support the request.  Please ensure that all appropriate information for each section is provided to avoid delays in processing your request. 

  • Applicant Information

  • Patient Information

  •  -  -
    Pick a Date
  • Clinician Information

  •  -
  • Medical History

  • Browse Files
    Cancel of
  • DRUG AND MEDICATION REQUEST FORM

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

  •  -  -
    Pick a Date
  • Browse Files
    Cancel of
  • Additional Information

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform