Pharmacy Assistance Application

Please fill out the following application and submit to our pharmacy. 

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Ethnicity
Do you have ANY TYPE OF PRECRIPTION INSURANCE?
Are you working with the Appalachian Healthcare Project?
Do you have Medicare:
Do you have Medicaid?
If you have Medicare but do not have Part D, have you applied for Medicare Part D?
Do your children have Medicaid or Healthchoice?
Are you receiving the Medicare Part D subsidy?
Do you receive Veteran Benefits?
If you are eligible but not receiving benefits, have you applied for Veteran's

BENEFITS

Are you recieving Disability Benefits?
Are you applying for Disability Benefits?
Are you recieving Disability Benefits?
Do you live in HUD housing?
Are you recieving Food Stamps?
Did you file taxes for the current year?

GROSS MONTHLY INCOME

WORK (SALARY + CASH PAYMENTS)

WORK FIRST

ALIMONY

applicant

spouse

other household members

TOTAL

CHILD SUPPORT

UNEMPLOYMENT COMPENSATION

SOCIAL SECURITY

SSI

VA BENEFIT

PENSION PAYMENTS

ANNUITY PAYMENTS

INVESTMENT FUNDS

OTHER SOURCES OF INCOME

TOTAL HOUSEHOLD INCOME

200% FPL for FAMILY SIZE

ASSET

VALUE 

If you listed any amount in question 12, please list all income producing assets.

TOTAL HOUSEHOLD ASSETS:

200% FPL FOR FAMILY SIZE:

DISCLOSURE INFORMATION

I hereby permit the Hunger and Health Coalition staff to contact any person or agency to discuss issues surrounding my application for assistance. I also verify that the information given above is truthful and that I have not made any attempts to misrepresent my need for assistance. 

Do you anticipate any significant changes in Household Income Assets?
Reevaluation Recommended In:

PHARMACY ASSISTANCE PROGRAM PATIENT INFORMATION

Drug Allergies
Do you need child resistant packaging?

THANK YOU FOR YOUR PHARMACY ASSISTANCE APPLICATION

A Pharmacy Technician will be with you in the next few days to review your application!