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| ELIGIBILITY
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| Eligibility
Info: |
Patient must have lived in the US or its territories for 6 months or longer.
Patient must meet program income guidelines.
Patient must uninsured or underinsured.
For Medicare Part D patients may be eligible, contact program for details. |
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Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
Yes |
| US citizenship/residency specified:
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Yes |
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APPLICATION |
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| Attachments
Required: |
Prescription
|
Physician
License #
Required: |
State
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Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
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| MEDICATION |
|
| Receives: |
Medication
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| Shipped To: |
Either Provider and Patient
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| Quantity in
Shipment: |
Varies |
| Delivery Time: |
Not Published
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| Re-application
Policy: |
New application at end of every enrollment period
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| Refill Policy: |
Varies by product |
| Other Information: |
Please visit www.SafetyNetFoundation.com for more information and applications. |
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