Medication Assistance Application

Medication Assistance Program Online Application Form

Caswell Family Medical Center’s medication assistance program helps patients that have no insurance or are underinsured receive medications that are important to improving the quality of their health.

Medications received through this program will be a brand name. Generic medications are available at the pharmacy for a discounted rate.

Medication Assistance Application Form

Name*
First Middle Last
Social Security Number*
Date of Birth*
Month
Day
Year
Phone
Email
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
Marital Status*
Employment Status*
Do You File Income Tax?*
Number in Household Including Yourself*
INSURANCE INFORMATION
Do you have insurance coverage?*
Do you have prescription coverage?*
Who is your insurance provider?
Do you have Medicare?*
Do you have Medicare Part D?*
Do you have Medicaid?*
If so, which Medicaid do you have?
Please provide Proof of Income (if any) below, No Income (IRS Non-filing form 4506 T), Medicaid Denial Letter (official written response upon completion of application at local Department of Social Services), Federal Tax Return Form 1040 (first and second page), and Self-Employment Schedule C of 1040 (if applicable).
File
Max. file size: 128 MB.
AUTHORIZATION
I verify that all information given is true to the best of my knowledge. I agree to contact CHC’s Medication Assistance Coordinator if any of the information given on these forms changes, including, but not limited to address and financial information. I authorize my Medication Assistance Coordinator to contact my physician(s) and exchange any information necessary to apply for free medications through The Pharmacy Connection. I also give my permission to exchange information with the pharmaceutical companies that manufacture my medications to access free medication. I authorize my Medication Assistance Coordinator to sign any necessary forms on my behalf when ordering medications for me, as this will speed up the ordering process by making it unnecessary for the forms to be sent to me and then back to CHC. This signature authorization is only valid if I am receiving services through Medication Assistance.

Not all medications will be available through Medication Assistance.

Medications typically come in a 3-month supply

There will be an annual renewal for medication assistance should I be found eligible to receive services (except in certain circumstances of prescription coverage).

You will be notified of medication availability. There will be a 21-day return policy on medications not picked up.

2 no shows to scheduled appointments, and/or non-compliance with the Primary Care Provider's recommendations, may result in dismissal from Medication Assistance for 1 year.

Medication will be picked up from North Village Pharmacy.

Any refills will need to be called in to the Medication Assistance Coordinator at CHC and must be called in by the patient.
Patient Signature*
First Last
Date*
Month
Day
Year
CAPTCHA
Phone

If you have questions or concerns about this form or any questions related to our Medication Assistance Program, please contact Donita Hairston at 336-694-1181, ext. 236, or by email at dhairston@caswellmedical.org

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Medication Assistance Program Online Application Form

Medication Assistance Application Form

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Medication Assistance Program Online Application Form

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