Get Lorain County Drug Repository Form

This guide provides clear, step-by-step instructions for completing the Lorain County Drug Repository Form online. By following this comprehensive guide, you will ensure that all necessary information is accurately provided to assist in gaining medication assistance.

Follow the steps to fill out the Lorain County Drug Repository Form online:

1. Press the ‘Get Form’ button to access the form and open it in your browser's editor.
2. Fill in the patient’s name and date of birth in the respective fields labeled 1a and DOB.
3. Provide the patient’s address, including city, state, and zip code in section 1b.
4. Enter the home phone number and alternate phone number in section 1c.
5. Indicate the yearly income by selecting the appropriate checkbox under section 2. Remember that eligibility requires an income under $60,000.
6. Specify the number of people living in the household in section 2.
7. Select the referral source by checking one of the options in section 3.
8. Fill in the referring agency’s name and contact details in section 4.
9. In section 5a, indicate whether the participant has any of the specified coverage options by checking the corresponding boxes.
10. Provide any additional comments regarding the participant’s coverage in section 5b.
11. Answer the question about obtaining medications via discount retail pharmacy programs in section 6.
12. State the reason for referral to the Drug Repository in section 7 by checking the appropriate options.
13. Outline the plan for long-term healthcare and medication assistance in section 8.
14. In section 9, authorize the referral source to share information by writing their name in the designated area.
15. Sign and date the form at the bottom as indicated, confirming that the information is correct.
16. Review all entered information for accuracy, and then choose to save changes, download, print, or share the completed form.

Complete your Lorain County Drug Repository Form online today to access required medication assistance.