Financial Support for Patient
Advocacy Organizations

Dermira is committed to providing support to nonprofit healthcare-related organizations that deliver programs, services, and activities that enhance the lives of patients living with chronic skin conditions.

Areas of Interest

Requestors may seek to support charitable activities such as patient community education or advocacy initiatives and programs intended to increase disease awareness or improvement in patient outcomes; particularly those that address the treatment of  hyperhidrosis and eczema.

Eligibility

Dermira will review charitable requests from US nonprofit organizations described in Sections 501(c)(3) and 501 (c)(6) of the U.S. Internal Revenue Code. including:

  • Patient advocacy organizations
  • Healthcare-related humanitarian organizations
  • Healthcare industry associations
  • Academic centers engaged in disease and patient education
  • Patient, professional, medical and scientific associations
  • Community service organizations

Requests that are outside the scope of Dermira’s Patient Advocacy and thus NOT ELIGIBLE include:

  • Investigator-Initiated Studies (IIS), (Please fill out the IIS form found here)
  • Promotional displays/exhibit fees, (Please fill out the Sponsorship form found here)

Required Materials for All Requests:

  • Submission of completed Dermira Patient Advocacy Organization Financial Support Application (find application below for download)
  • Letter of Request (LOR) on nonprofit organization’s letterhead that includes:
    • Program/Activity title
    • Description of the proposed program/activity with goals and objectives
    • Start date and end date of the program/activity
    • Audience description and anticipated number of attendees
    • Estimated overall budget for the program/activity and amount of funding requested from Dermira. Please designate if multiple funding sources are being requested.
  • W-9 Form of your organization (provided annually)
  • Detailed budget for program/activity
  • Agenda, if applicable for program. If not available, please submit titles and topics to be covered in program /project/event and detailed budget showing all costs
  • Copy of current 990 Form (provided annually)
  • Copy of 501(c)(3) or 501(c)(6) tax-exempt charitable status (provided annually)

Form Downloads

Please download the application, fill out completely and return along with the above required materials via email apply.patientadvocacy@dermira.com or mail printouts to:
Patient Advocacy Coordinator
275 Middlefield Road, Suite 150
Menlo Park, CA 94025.

If you are emailing, an electronic signature will be required.


Dermira Patient Advocacy Organization Financial Support Application (in fillable PDF and Word formats for download)

doc
pdf

Please see our Privacy Policy regarding data submitted via application forms.

Compliance Commitment


Applications will be considered for review only upon submission of all above documentation. Dermira will generally review an application within 45-60 days of submission. Dermira will provide an email notification upon approval or denial of this application.
Dermira complies with all federal, state and local country laws, as well as industry and academic codes and guidelines that govern such charitable contribution activities. In addition, Dermira sets strict standards on all interactions with patient organization leaders, healthcare professionals and other community partners.
Dermira does not receive any significant value in terms of goods or services in return for its support to patient advocacy organizations. Dermira reserves the right to modify, revise or delete the terms and conditions of its charitable giving program at any time and without notice.

To inquire directly about current areas of interest and for any other questions, please contact us at patientadvocacy@dermira.com.