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    Pre-Qualifying App 2013

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    api-233271821
    This document is a pre-qualifying application for a medication assistance program which collects personal information such as name, address, contact details, income verification, and eligibility requirements including proof of address, income, and lack of other prescription drug coverage from applicants. It informs applicants that they must update their application and documentation every 6 months, be responsible for refill requests, and provides contact information to submit the completed, signed application.

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    Download as PDF, TXT or read online from Scribd

    Pre-Qualifying App 2013

    Uploaded by

    api-233271821
    1K views1 page
    This document is a pre-qualifying application for a medication assistance program which collects personal information such as name, address, contact details, income verification, and eligibility requirements including proof of address, income, and lack of other prescription drug coverage from applicants. It informs applicants that they must update their application and documentation every 6 months, be responsible for refill requests, and provides contact information to submit the completed, signed application.

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    This document is a pre-qualifying application for a medication assistance program which collects personal information such as name, address, contact details, income verification, and eligibility requirements including proof of address, income, and lack of other prescription drug coverage from applicants. It informs applicants that they must update their application and documentation every 6 months, be responsible for refill requests, and provides contact information to submit the completed, signed application.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views1 page

    Pre-Qualifying App 2013

    Uploaded by

    api-233271821
    This document is a pre-qualifying application for a medication assistance program which collects personal information such as name, address, contact details, income verification, and eligibility requirements including proof of address, income, and lack of other prescription drug coverage from applicants. It informs applicants that they must update their application and documentation every 6 months, be responsible for refill requests, and provides contact information to submit the completed, signed application.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    of 1

    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

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