Get Coverrx Application

Completing the CoverRx Application online is an essential step for individuals seeking pharmacy assistance. This guide provides user-friendly instructions to help you accurately fill out the application form, ensuring you provide all necessary information.

Follow the steps to complete the application process.

1. Click ‘Get Form’ button to access the application and open it in your preferred editor.
2. Enter your last name, first name, and middle initial in the respective fields. Ensure that each section is filled out completely.
3. Select your gender by choosing either 'Male' or 'Female'. Additionally, fill in your date of birth.
4. Provide your social security number in the designated field, then indicate the number of people in your household.
5. Enter your yearly household income. This is a required field, so ensure the amount is accurate.
6. Fill in your home phone number. If you do not have one, write 'N/A' and also include your email address.
7. If applicable, enter your cell phone number or write 'N/A'. Mark whether you would like to receive text messages about CoverRx.
8. Provide your house address, city, state, zip code, and county. If your mailing address is different, include that information as well.
9. Indicate your race for Title VI purposes and the language you speak, if applicable.
10. Answer the eligibility questions regarding U.S. citizenship, recent residency in Tennessee, and existing health insurance.
11. Review the terms and conditions section, ensuring comprehension and acceptance by signing at the end of the form.
12. Once you have completed all sections, save any changes, download a copy of the application, or print it for submission.

Take the next step towards receiving assistance by completing your CoverRx Application online today.