Registration for Support and Access Services for Compassionate Use Treatment
Trial-In Pharma will provide professional support services to the patient to assess suitability and submit an application for treatment under a Compassionate Use Program (Expanded Access).
The service includes, as needed:
- Initial eligibility assessment
- Collection, review, and preparation of medical documents
- Translation of medical documents as required
- Submission of documents to relevant medical authorities
- Coordination and support with various hospitals, the physician, and any relevant medical entity
- Assistance with completing additional documents and information as required
- Ongoing guidance throughout the process until a decision is reached
Medical Waiver Form
To initiate the process and review the medical file, please fill out and digitally sign the medical confidentiality waiver form on the secure system.
To complete and sign the confidentiality waiver form >>Program Registration Form
Please fill out the official registration form to receive support and accessibility services for the Compassionate Use Program.
Proceed to complete the digital registration form >>Submission of Medical Documentation
Please send us the following medical documents scanned as PDF files:
- 1. Summary of the latest visit with the treating oncologist
- 2. Pathology report
- 3. 2 recent imaging reports (CT, MRI)
- 4. 2 recent detailed blood tests: CBC, CMP, coagulation panel (PT/PTT/INR), including markers, Albumin, ALT, AST, Bilirubin
- 5. Molecular testing - NGS (if available)
- 6. Copy of passport and copy of U.S. visa
- Email: contact@trial-in.com
- Office WhatsApp: 058-444-5108
Payment Arrangement
Payment for the support service is a one-time fee (not a monthly fee) and is settled directly with the company's offices.
Payment can be made via bank transfer, standing order, or credit card:
Beneficiary Name: Trial-In Pharma Ltd.
Bank: Bank Otsar Ha-Hayal (14) | Branch: 345 | Account: 182472
* Please send transfer confirmation for notification and tax invoice issuance.
For details regarding service cost and to receive a secure payment link (up to 4 installments by credit card), please contact our office directly by phone/WhatsApp or email.
- Initial one-time Zoom consultation with the hospital – $750
- Administrative fee for receiving the medication – $2,500
- Follow-up Zoom consultations after returning to Israel: approx. $250 - $750
- Flights, accommodation, and stay in the United States
- Hospitalizations/additional tests abroad (comprehensive medical insurance required)
Patient Declarations and Terms of Engagement
- The company provides guidance, coordination, and accessibility services only. It does not manufacture the medication and does not operate the treatment program.
- The decision on whether to accept the patient into the program, offer treatment, or provide the medication rests exclusively at the discretion of the physician, the hospitals, the pharmaceutical company, or any other authorized medical authority. The company does not guarantee any medical outcome or acceptance into the program.
- Compassionate use programs may change, close, or be discontinued at any time, beyond the company's control.
- I agree that the company may retain, process, and transfer the medical and personal information I provide solely for the purpose of executing the service and in accordance with law requirements.
The engagement takes effect upon the patient's signature, receipt of all documents, and payment settlement. Since the service is customized and includes reviewing the file and preparing documents – once the company has begun actually executing the service, the engagement cannot be canceled, and no refund will be provided, unless decided otherwise by the company at its sole discretion.
The company shall be entitled to terminate the service without refund in cases of providing false/misleading information, lack of cooperation from the patient, or inappropriate behavior toward company staff.
✓ Signing the forms and completing the steps constitutes full acceptance of these terms.
