Medical Prescription Assistance

Medical Prescription Assistance
Have you applied or are you eligible for Medicaid?*

YesNo
Did you know that Medicaid was expanded on July 1, 2021 and you may be eligible? If you would like to apply or reapply, please go to www.mysoonercare.org or call 1-800-987-7767 for more information.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Work Status*

EmployedUnemployedRetired
Reason you are unemployed?
Primary Physician Name*

First NameLast Name
Primary Physician Phone Number*

Area CodePhone Number
Primary Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Prescription(s) Requested:*

	Rx Name	Strength (mg)	Number taken per day	Price Quoted	Prescriber/Physician Name	Treatment for what medical condition?
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8
Prescription 9
Prescription 10

Have you received assistance from CDSA in the past?*
When did you receive assistance from CDSA?
What program from CDSA helped you in the past?
Is there anything else you would like us to know?
Do you live in Garfield or Grant County, Oklahoma?*

Garfield County, OKGrant County, OKNo, I do not live in Garfield or Grant County, OK
Do you live in Enid, Oklahoma?

YesNo
How many people are in your household?*
How much is your household's total yearly income?*
Should be Empty: