Applying for the Fill the Gap Program is quick and straightforward — most people finish in under 5 minutes. Whether you're applying for yourself or on behalf of someone else, we're here to help.

A few helpful resources before you begin:

Review eligibility and available medications → Rx Outreach Fill the Gap Program
Questions about the process? → Frequently Asked Questions

Not sure if Fill the Gap is right for you? If you find you don't meet the eligibility requirements, Rx Outreach may still be able to help. Visit rxoutreach.org/patients
or call us at 314.222.0472 or 888.796.1234.

Note: This form only collects information you provide directly — your details are not captured automatically.

Ready? Let's get started.

* Required 

Step 1: Confirm Eligibility Criteria
Patients must meet all the criteria listed below.  Eligibility will be verified using Experian Health Hub Services. 

If you find you don't meet the eligibility requirements, Rx Outreach may still be able to help. Visit rxoutreach.org/patients or call us at 314.222.0472 or 888.796.1234.

Step 2: Patient Information

Step 4: Referral Information

Step 4: Disclosures & Consent to the Program Terms and Conditions

I authorize Rx Outreach to administer the Program in accordance with the Terms and Conditions and to do the following:

1. Use any information that I provide in my application for the purpose of helping me receive the products under the Program or to administer the Program. 
2. Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the Program.  
3. Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to administer the Program. 
4. I understand that the Fill the Gap program is designed to assist patients who are unable to access the medications they need due to lack of full insurance coverage. This includes individuals who are uninsured or underinsured. By submitting this form, I authorize Rx Outreach to collect information about my insurance status, medication coverage, and prescription needs. This information will be used solely to determine eligibility and improve services for individuals with limited access to affordable prescriptions. I understand that providing false information may result in disqualification from the program. My data will be kept confidential and used only in accordance with applicable privacy laws.
5. Authorize Rx Outreach to obtain a consumer report on me, including through Experian, to verify my income and ensure compliance with the stated eligibility criteria. My consumer report and the information derived from public and other sources will be used to estimate my income as part of the process to determine if I am eligible to receive free medication in the Program.
6. Request additional documents and information at any time, even if I am already enrolled, so that they can determine if the information on this form is complete and true. 
7. Disclose any information obtained from the sources listed above to third parties if required by law. I understand that neither Rx Outreach charges a fee for participation in the Program. If I have used a third party who charges a fee for help with my enrollment form or refills of my medicine, this money is not paid to Rx Outreach. I understand the authorizations provided by me in connection with the Program, including the above authorizations, will remain in effect for as long as I participate in the Program and for up to [7 years after my participation in the Program ends]. 
8. This is a grant-funded pilot program, and surveys are required to participate in the program. It helps us improve our services and ensure that we are providing the best possible support to our participants. You can expect a survey at enrollment and outreach for surveys at 6 months and 12 months. You may be removed from the program if we cannot reach you for those.

Please Allow at least 2 business days for processing.
Rx Outreach will contact you.

I also understand that I have the right to revoke this authorization at any time by calling 1-866-578-2444, and mailing a signed written statement of my revocation to the Program. Such a revocation would end my eligibility to participate in the Program. Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been taken in reliance on my authorization. I understand that once medical information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by federal privacy laws and may be further disclosed. I understand that I am providing written instructions to Rx Outreach under the Fair Credit Reporting Act authorizing Rx Outreach to obtain information from my credit profile or other information from Experian Health or another third party credit bureau. I authorize Rx Outreach to obtain such information solely for the purpose of determining financial qualification from the Program. I certify that I have read, understand and will abide by the Program Terms and Conditions. I certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that Rx Outreach may contact me about this application, the Program, and my prescription via phone, text, email, and/or mail. Message and data rates may apply. You can opt out by calling 1-866-578-2444. For additional information about how Rx Outreach handles your information, please see Rx Outreach’s privacy notice https://rxoutreach.org/privacy-policy/
. Rx Outreach will not share any patient specific information, including any patient health information or financial information. By submitting this application, I agree to the Program Terms and Conditions.