Request Affordable Prescriptions

RECERTIFICATION FOR AFFORDABLE PRESCRIPTIONS
In order to remain on our program, you need to re-certify to maintain your eligibility to receive prescriptions.
- Have a current US Michigan Drivers License or Michigan State ID.
- Are 18 years of age or older.
- Earn $44,800 or less per year if you are single; $51,200 for a couple.
Please note: All invoices must be paid before placing your next order. Any return checks for insufficient funds will carry a fee and be added to your next invoice.

If you have any questions, please call 313.866.5333.
Name*

First nameLast name
Phone number*
Please enter a valid phone number.
Email Address*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Marital Status*
Disability Status*
Employment Status*
Emergency contact name*
Emergency contact phone number*
Please enter a valid phone number.

MEDICAL INFORMATION
Please list ALL of the prescription medications you are currently taking that World Medical Relief's Pharmacy has been unable to fill. We may be able to suggest another comparable medication to check out with your physician.*
Please list any allergies to medications (if none, type "None")*

HOUSEHOLD INCOME INFORMATION
Total Monthly Household Income (please include ALL sources of income including Net wages, Social Security, S.S. Disability, Unemployment, Tax stmt-1040, Pension, Medicaid, Bridge Card Statement, Alimony, Food Stamps, or any other sources of income)*
For this application to be approved, you must include documentation of your monthly household income: Social Security statement, pay stub, unemployment information, pension information, copy of bridge card, etc.*

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RECERTIFICATION SURVEY
How much do you spend per month for my prescription medicines received from World Medical Relief.*
How much do you spend per month for medications that you cannot get from World Medical Relief?*
I worry less about having enough money to buy my prescription medications since being on the program.*
I often have to make a choice between buying my prescription medications or paying my bills (like rent, telephone, utilities, food, etc.) since I have been on the Affordable Prescription Program.*
I believe I have fewer health problems now than I did before I joined the prescription program.*
Please rate how easy it is to manage your health problemsRight now I can better manage my health problems (i.e. get to doctor appointments when scheduled; buy needed foods and medicines, receive physical therapy when needed, etc.) than before I was on the Affordable Prescription Program.*
I generally feel more energetic, active, and physically well despite any health problems, since I joined the Affordable Prescription Program.*
If I need to go to the drug store, see a doctor or dentist, or participate in other medical appointments, I can get there on my own without help from family or a caregiver.*
COMMENTS: (Please let us know how we are doing, and if you have any suggestions for improvement.)*

Health Insurance Portability and Accountability Act (HIPAA)
Effective April 14, 2003 the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that World Medical Relief comply with certain rules regarding maintaining privacy of your medical information that we have collected and will collect in the future. This applies to the information you provided World Medical Relief when you applied for the Affordable Prescription Program as well as information regarding the prescriptions we are receiving and filling for you from your physician.

Existing Michigan law requires us to obtain, or attempt to obtain, your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a court order as part of a criminal investigation; or a licensure investigation.

From time to time it may be necessary for us to make disclosure of your information.
Patient Name*
Signature*

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PATIENT ACKNOWLEDGEMENT & CONSENT

Please sign this form below to acknowledge that you have today received a copy of our notice of privacy practices and you consent to our disclosures of your information that we deem necessary in order to provide you with the proper services of the Affordable Prescription Program.
Patient Name*
Signature*

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ADDITIONAL INFORMATION
How did you hear about us?
The handling fee is $8.30 (+ $4.50 shipping in some scenarios) for each prescription dispensed. Are you able to pay for the handling fee?*

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For this application to be approved, you must include copy of your ID*

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I'm not a robot*
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RECERTIFICATION FOR AFFORDABLE PRESCRIPTIONS

MEDICAL INFORMATION

HOUSEHOLD INCOME INFORMATION

RECERTIFICATION SURVEY

Health Insurance Portability and Accountability Act (HIPAA)

ADDITIONAL INFORMATION