Summary

Name: {name-1}

Email Address: {email-1}

Phone: {phone-1}

Address: {address-3}

Apartment: {address-2}

Location: {address-1}

How did you hear about us? {select-1}

Consent: {consent-1}

Summary

Do you currently have income? {radio-1}

Do you file taxes? {radio-3}

Are you a US Citizen? {radio-2}

Are you currently employed? {select-2}

Are you married? {select-3}

How many people live in your household? * {number-1}

Have you applied for Medicaid? {radio-4}

If yes, did you receive a denial letter? {radio-5}

Are you on Medicare? {radio-6}

Do you have Medicare Part D? {radio-7}

Are you in the coverage gap? {radio-8}

How much money have you spent out of pocket on your prescriptions for the current year? {number-2}

Have you applied for Low Income Subsidy (LIS)? {radio-9}

If yes, did you receive a denial letter? {radio-10}

Are you disabled as determined by Social Security? {radio-11}

After enrolling, we will verify the income requirements for the medications you are requesting. If after verification we are unable to assist you with that medication we will notify you and return any fees that we have charged you automatically. Put the correct number in the box(es) for the type(s) of income you receive monthly.: {group-12}

Summary

Healthcare Provider's First Name: {name-4}

Healthcare Provider's Last Name: {name-12}

Facility Name: {name-5}

Address: {address-5}

Phone: {phone-2}

Fax Number: {phone-3}

Medications: {group-1}

Do you have more healthcare provider(s) to add who prescribe other medication for you? If so, please fill out the next section. {radio-13}

 

---

 

Healthcare Provider's First Name: {name-10}

Healthcare Provider's Last Name: {name-9}

Facility Name: {name-11}

Address: {address-4}

Phone: {phone-4}

Fax Number: {phone-5}

Medications: {group-13}

 

---

 

Healthcare Provider's First Name: {name-2}

Healthcare Provider's Last Name: {name-13}

Facility Name: {name-3}

Address: {address-6}

Phone: {phone-8}

Fax Number: {phone-7}

Medications: {group-17}

Consent: {consent-2}

Summary

Gender: {radio-16}

Is this form on behalf of a minor? {radio-17}

Parent/Guardian First Name: {name-8}

Parent/Guardian Middle Initial: {name-14}

Parent/Guardian Last Name: {name-7}

Parent/Guardian Phone: {phone-6}

DOB: {date-1}

SSN: {text-1}

Consent: {consent-7}

Summary

Name: {name-15}

Address: {address-7}

Card: {stripe-1}

Consent: {consent-6}