Application Checklist

The following items must be submitted by mail or by fax to complete your application, even if you have completed the application online.

  1. A completed application, signed and dated by you and your prescriber.
  2. The completed prescription on page 3 of the application.
    • If your current household income is zero, a letter explaining your financial situation from a family member, healthcare provider, or yourself
  3. If you are a Medicare enrollee, please also include:
    • A copy of your Medicare Part B and/or Medicare Part D Prescription Drug statement (Explanation of Benefits [EOB]), a pharmacy printout, or a summary document from your pharmacy indicating the amount you have spent on prescriptions in the current calendar year; this total should be at least 3% of your income

If you’ve experienced recent financial hardship and your financial documentation from last year does not accurately reflect your current situation, you’ll need to include supporting documentation explaining how your circumstances have changed. These forms include:

  • Employer or unemployment office letter
  • A copy of marriage certificate or divorce decree to explain a change in marital status
  • A copy of a birth or death certificate to explain a change in household number