Medication Assist

Patient Pre-Qualifying Application

(One Application per person. Please print clearly)
Name: _____________________________________________________________ Address: ______________________________________________________
City: ________________________________ State: ___________ Zip: _____________Phone: (______)______________ Fax: (______)_____________
SSN: _______-_______-_______ DOB: _______/_______/_______ Martial Status (please check one): ____S ____M ____W ____D
E-Mail Address: ____________________________________________________________________________________________________________________
US Citizen: ________Yes ________No

Gender: ________M ________F How many people are in the household:____________

Are you on Medicare: ______Yes ______No Medicare Part D: ______Yes ______No

Are you Disabled: _____Yes _____No

Employment Status: _______Retired _______Unemployed _______Full-Time _______Part-Time

Alternative Contact Name: ________________________________________________ Contact Number: (______) ________________________
Disease or Medical Condition: _________________________________________ Drug or Food Allergies: ___________________________

Proof of Income
(MANDATORY FOR PROGRAM APPROVAL)

Eligibility Check List

Current Application and Documentation must be updated every 6 months.
MUST INCLUDE ONE OF THE FOLLOWING DOCUMENTS
Address Verification
Drivers License: _____ Current Utility Bill: _____Letter from Shelter: _____ Family Support letter: _______ other: ______
MUST INCLUDE ONE OF THE FOLLOWING DOCUMENTS
Income Verification
Form 1040: ______ Form 4506T: ______ Form W-2: ______ Payroll Check Stub: ______ Letter from Employer: ____________
Unemployment Documentation: ______ Social Security Statement: _____ Food Stamp Letter: _______ Other: ___________
No other form of prescription drug coverage (supporting documentation not needed): ______________________________
Patient Id Number:________________
Failure to provide the following documentations will result in medication delay or denial.
You are responsible for you your refill requests. DO NOT WAIT until you are completely out of medication.

Patient Signature

Patient Signature: __________________________________________________________________________________ Date: ________________________

Please complete, sign, and mail or fax in the application to the address below
711 Stanton L. Young Blvd. Suite#100
Oklahoma City, OK 73104
Office: 405-271-6278 Fax: 405-271-6287