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Welcome
Welcome
Please complete the following form to participate in the Prescription Plus Program, offered by United Samaritans Foundation, Boies' Medical Center Pharmacy, Legacy Health Endowment, and EMC Health Foundation.
Prescription Plus Program English
  • 1
    What is the patient's name, phone number, and residency zip code.
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  • 2
    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
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  • 3
    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
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  • 4
    Does the patient currently have medical insurance?
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  • 5
    Who 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...
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  • 6
    The patient has a current prescription from a doctor for the medication they are applying for.
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  • 7
    Does the patient have a current prescription for insulin?
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  • 8
    Are you using a mobile device or a computer to fill out this application?
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  • 9
    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).
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  • 10
    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).
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    Select files to upload
    Max. file size: 10.6MB
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  • 11
    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.
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