Language
English (US)
Spanish (Latin America)
Life-Threatening Prescribed Medication Assistance
Assistance is provided ONLY for life-threatening prescriptions. Applications that are incomplete, missing documentation, submitted after the requested deadline, or are not considered a life-threatening prescribed medication will not be reviewed and will be denied immediately. Applicants may be referred to additional community resources when appropriate.
Name
*
First Name
Last Name
Last 4 of SSN
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
(1) Upload Documents: picture of ID of all household members over 18.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please tell us why you need assistance with your medication?
(2) Upload Documents: picture of Social Security Card for all household members.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
(3) Upload Documents: picture of Insurance/Medicaid/Medicare Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of Insurance Provider
If no insurance please put N/A in box above
Copay Amount
(4) Upload Documents: Income -PLEASE UPLOAD ALL MONTHLY SOURCES OF INCOME
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
(5)Upload Documents: picture of prescription
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of Medication
*
Pharmacy Name
*
Pharmacy Phone Number
*
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Your form is complete. Please give us 24 hours to process your request and we will get back with you. Thank you!
Submit
Should be Empty: