1. Patient can NOT have prescription coverage
2. Patient must be at or below the 200% Poverty Income*.
3. Patient must take prescribed medication and can not afford to buy them with the income allotted.

WHAT YOU WILL NEED:

1. List of your medications
   - Include the dosage, how often you are taking it, and the prescribing doctor
2. Prescribing Physician's Information
   - Include address, phone number. List any and all doctors that will be prescribing you medication
3. Financials
   - Fax Form 1040 (from previous year)
   - If you did not file taxes, you will need to fill out a 4506T
   - W-2
   - Paycheck Stubs (for the past MONTH)
   - Most Recent Bank Statement
   - Social Security/ Disability Statement
4. Correspondence
   - Photo ID
   - Green Card (if applicable)
   - Any denial letters from any private insurance or government program

*Poverty Chart Source: Federal Register Vol. 73, No. 15, January 23, 2008, pp. 3971-3972. Monthly and yearly percentage data calculated by FHCE and rounded to the nearest dollar

DRUG ASSISTANCE PROGRAMS