Skip to content
  • Services
    • Independent Patient
    • Institutional Facilities
    • Clozaril/Clozapine Program
    • Portal Access
  • COVID-19
    • COVID-19 Vaccinations
    • COVID 19- Oral Treatments
  • Clozaril/Clozapine Program
    • About the Program
    • About Clozaril/Clozapine
    • About The Athelas Home Device
    • Application for Clozaril Program
    • Frequently Asked Questions
  • Make Payment
  • General Info
    • About Us
    • Contact Us
    • Shipping Map
    • HIPAA Privacy Policy
  • en English
    en Englishes Spanish
Golden Gate Pharmacy Services Inc
  • Services
    • Independent Patient
    • Institutional Facilities
    • Clozaril/Clozapine Program
    • Portal Access
  • COVID-19
    • COVID-19 Vaccinations
    • COVID 19- Oral Treatments
  • Clozaril/Clozapine Program
    • About the Program
    • About Clozaril/Clozapine
    • About The Athelas Home Device
    • Application for Clozaril Program
    • Frequently Asked Questions
  • Make Payment
  • General Info
    • About Us
    • Contact Us
    • Shipping Map
    • HIPAA Privacy Policy
  • en English
    en Englishes Spanish

© 2019

Your Health Simply Delivered

Application for Clozaril Program

Please complete the following fields accurately and completely if you would like Golden Gate Pharmacy to determine if you are eligible for our program. Any blank or incorrect information may cause a delay.

Step 1 of 13

7%
I am Currently(Required)

Personal Information

Name(Required)
MM slash DD slash YYYY
Address(Required)
Is this your shipping address?(Required)
Shipping Address(Required)

Insurance Information

Max. file size: 32 MB.
Max. file size: 32 MB.
Do you have other Insurance to Add?(Required)

Insurance Information #2

Max. file size: 32 MB.
Max. file size: 32 MB.
Do you have other Insurance to Add?(Required)

Insurance Information #3

Max. file size: 32 MB.
Max. file size: 32 MB.

Doctor Information

Doctor Name(Required)

Pharmacy Information

If Eligible(Required)
Max. file size: 32 MB.
Known Allergies:(Required)

Athelas

I am interested in getting information about the Athelas Home finger stick blood testing device(Required)
Athelas Home

If Applicable Only:

HIPPA

Do you already have an authorization from to release protected health information (PHI) to Golden Gate Pharmacy Services?(Required)
Drop files here or
Max. file size: 32 MB.
    Re: Patient Name(Required)
    MM slash DD slash YYYY
    to: Name of Representative(Required)
    (Family member, advocate, Power of Attorney etc)
    Address(Required)
    MM slash DD slash YYYY
    information:(Required)
    Reset signature Signature locked. Reset to sign again
    MM slash DD slash YYYY
    Printed Name of Person Signing(Required)

    Acknowledgements

    Automatic Refill Program(Required)
    (Required)
    Packaging(Required)
    (Required)
    Branded medication(Required)
    (Required)
    Test Claim(Required)
    (Required)
    Term of Services(Required)
    (Required)
    Athelas(Required)
    (Required)
    HIPAA(Required)
    (Required)
    Reset signature Signature locked. Reset to sign again

    Contact Us

    About Us

    Shipping Map

    User Portal

    Make Payment

    © 2023 Golden Gate Pharmacy Services Inc. 8 Digital Drive, Suite 200 Novato, CA 94949