Rx Prescription

Qualify For Free Or Reduced Costs Medications Today!

Submit this questionnaire and you will be able to research your medications/diabetes testing supplies to see if you qualify for Patient Assistance Programs. All answers are required in order to complete the research.

Please note: you must have Adobe Acrobat Reader installed on your computer to view our printable documents. To install Adobe Acrobat Reader to your computer, please click on the button to the left.

PATIENT ELIGIBILITY QUESTIONNAIRE

Complete and submit this questionnaire and if you are eligible to apply, your next step will be selection of your medications. If you have previously created an account, click here.

Note that those 65 and older and/or eligible or enrolled in Medicare Part D are not eligible for these patient assistance programs.

First Name:

Middle Initial:

Last Name:

Address:

Apartment #, if any:

City:

State:

Zip:

How many people live in the household?:

What is your yearly gross household income?: $

What is your monthly gross household income?: $

Are you a US Citizen?:

YesNo

Date Of Birth:

Phone:

(ex: 123-123-1234)

Gender:

MaleFemale

Are you a U.S. Veteran and/or eligible for VA prescription benefits?:

YesNo

Email:

Confirmation Email:

Are you ELIGIBLE FOR or ENROLLED IN ANY prescription drug plan for your medications? This includes MEDICAID, MEDICARE PART D, PRIVATE INSURANCE, VETERANS PLAN OR STATE SCHIP/SCAP:

YesNo

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©2007 Rx Meds Partner
RX MEDS PARTNER is not affiliated in any way with pharmaceutical companies. We do not receive any payment from any company, only from the consumer/patient. We cannot guarantee eligibility until each company has reviewed your application and replied with a decision. Doctor's participation and prescription is required for each application. Identification and documents such as proof of income and U.S. citizenship may be needed for each application if you decide to apply for free prescriptions or other benefits.