Get Carilion Medication Assistance Program

The Carilion Medication Assistance Program is designed to help individuals access the necessary prescription medications they require but may not afford. This guide provides step-by-step instructions for completing the online application accurately and efficiently.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to acquire the Medication Assistance Program application form and open it for editing.
2. Fill in your personal details, including your name, date of birth, and Social Security number. Ensure all information is accurate and complete.
3. Provide your contact information, which includes your mailing address, physical address (if different), and phone numbers. This will help maintain communication regarding your application.
4. Select your gender, ethnicity, marital status, and whether you are a U.S. citizen. This information aids in demographic assessment and eligibility.
5. List the medications you are currently taking, including their strengths, dosages, reasons for use, and the prescriber’s name. Properly documenting your medication history is essential.
6. Complete the household information section, including members of your household, ages, income types, and gross amounts. Accurate income documentation is crucial for consideration.
7. If applicable, provide information regarding any insurance coverage, including Medicare and other assistance programs. Include documentation where necessary.
8. Review the consent and signature sections carefully. These affirm your understanding of the program guidelines and your agreement for information sharing.
9. Once the application is completed, save your changes. You have the option to download, print, or share your form as needed.

Complete your Carilion Medication Assistance Program application online today to ensure you receive the support you need.