Prescription Plus Program English

1
Patient InformationWhat is the patient's name, phone number, and residency zip code.
Patient's First Name
Patient's Last Name
Patient's Phone Number
Patient's Residency Zip Code
Patient's Email Address (optional)
2
Household Income* This field is required.To be eligible, the patient's household income must be equal to or below the following annual incomes based on occupancy. Please select one of the following that best suits your situation.
1 Person Household - Equal to or below $38,280
2 Person Household - Equal to or below $52,720
3 Person Household - Equal to or below $65,160
4 Person Household - Equal to or below $78,600
5 Person Household - Equal to or below $92,040
6 Person Household - Equal to or below $105,480
7 Person Household - Equal to or below $118,920
8 Person Household - Equal to or below $132,360
9 Person Household - Equal to or below $136,840
10 Person Household - Equal to or below $141,320
11+ Person Household - Income varies based on total
3
Household Income* This field is required.To be eligible, the patient's household income must be equal to or below the following annual incomes based on occupancy. Please select one of the following that best suits your situation.
1 Person Household - Equal to or below $38,280
2 Person Household - Equal to or below $52,720
3 Person Household - Equal to or below $65,160
4 Person Household - Equal to or below $78,600
5 Person Household - Equal to or below $92,040
6 Person Household - Equal to or below $105,480
7 Person Household - Equal to or below $118,920
8 Person Household - Equal to or below $132,360
9 Person Household - Equal to or below $136,840
10 Person Household - Equal to or below $141,320
11+ Person Household - Income varies based on total
Please enter your household yearly income
4
Medical Insurance* This field is required.Does the patient currently have medical insurance?
YESNO
5
Medical Insurance ProviderWho is the patient's medical insurance provider?
Blue Shield of California
Blue Cross of California
Kaiser
Sutter/BCBS
Anthem
Medi-Cal
Medicare
Health Plan of San Joaquin
Central California Alliance for Health
Caremore
HealthNet
Other...
Medical Insurance Provider
If Other, Please List the Provider Name
Patient's Policy Number
6
Prescription Verification* This field is required.The patient has a current prescription from a doctor for the medication they are applying for.
YESNO
7
Prescription for Insulin* This field is required.Does the patient have a current prescription for insulin?
YESNO
8
Proof of Residency* This field is required.Are you using a mobile device or a computer to fill out this application?
I am using a mobile device (smartphone, tablet)
I am using a computer (desktop, laptop)
9
Mobile Device Address Verification* This field is required.Please take a picture of proof of residency (examples - current driver's license, current state ID, electricity bill, gas bill, water/sewer/garbage bill, internet provider bill, cable bill).
10
Computer Address Verification* This field is required.Please upload a picture or file of proof of residency (examples - current driver's license, current state ID, electricity bill, gas bill, water/sewer/garbage bill, internet provider bill, cable bill).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
* This field is required.I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of services.
YESNO
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