Rx for Oklahoma

Washita Valley Community Action Council

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Rx for Oklahoma

Prescription Drug Program

Mission:

“Our mission is to assist the medically underserved in obtaining a supply of medication they would otherwise be unable to afford.”

**** No Fee to Apply ****

Rx for Oklahoma…

Washita Valley Community Action Council’s Rx for Oklahoma is a program designed to help persons in Grady and Caddo Counties access prescriptions for much needed medications that can be received either free of charge, or with a small co-pay.

Many people who need the prescriptions are not aware of the long-standing manufacturers’ assistance programs available, or they are unable to access and complete the long and sometimes complicated individual forms.

Rx for Oklahoma helps individuals with this process by entering personal information, including financial documentation, and their prescription medication needs into a medication assistance computer program. Once assessed, a list of medications suited to a particular patient’s needs is displayed on the computer screen and the appropriate forms are printed out, with all information included.

If the medication is available, the medication is then sent to any qualified individual’s home or doctor’s office, usually within 4 to 6 weeks.

There is no charge for this service, which takes care of paper work and links individuals directly with free or low-cost medications. If you feel you may qualify for this program, please print out the application that follows, fill out, sign, and send to Rx for Oklahoma at the address shown on the application. We will then call you for an appointment to assess whether or not you qualify for the prescription program.

Note: We Cannot guarantee the approval for any program, as each decision is made by the pharmaceutical company.

Assistance in completing the application may be obtained at the offices of Washita Valley CAC located at the Chickasha Commercial Center building,

205 W. Chickasha Ave., Chickasha, OK

.

For more information about this program, please contact:
Juli Bowen

405-224-5831 ext. 107

DOCUMENTATION NEEDED WITH COMPLETED Rx APPLICATION

Drivers License (Picture ID)

Social Security Card

Insurance Card(s) (if applicable)

Income Tax Return

1099 from Social Security (if applicable)

30 day Income Verification (check stubs, Social Security

income letter, ect.)

Medicaid Denial Letter (if applicable)

For appointment Call
405-224-5831 ext. 107

Rx Oklahoma

Washita Valley Community Action Council:
205 West Chickasha Avenue
P.O. Box 747
Chickasha, OK 73023
Phone: 405-224-5831 ext 107
Fax: 405-222-4303
Toll Free: 1-866-400-0642
jbowen@wvcac.chickasha.ok.us

PLEASE PRINT **PLEASE COPY ALL
INSURANCE
CARDS AND ATTACH
FINANCIAL VERIFICATION:

_________________________________

(Date)

Have we assisted you before: YES NO:

Name:
(First) (MI)

(Last)

Address:

City:    Zip:

County:   State:

Phone:    Sex:

SSN:

Date of Birth:   Language:

Household: Head Spouse Dependent Child

Employment: Full Part Retired
Not in Labor ForceUnemployment

Race:   Marrial Status:

Education Level:

U.S. Citizen:YESNO U.S Resident: YESNO

Veteran: YESNO

How did you hear about this program?
Action AgencySenior AdvisorLegislative Office

Community ClinicFliersNewspaperSocial Services

Doctors Office Health Department Website/Internet

Friend/Family Presentation DHS TV/Radio

Areawide Aging Agency Employer Hospital

Word of Mouth Other

Insuance Information: PLEASE COPY AND ATTACH ALL INSURANCE
CARDS, FRONT AND BACK.

Please check all that apply

Medicare (Medicare # ) Medicaid

Medicare Discount Card None

Private Health Insurance (Company )

Do you have prescription insurance? YESNO

Number in Household: Adults
Children

Housing: Own Rent Stay with Family/Friends

Did you file a tax return last year? YESNO
Will you file a tax return this year?YES NO

Please enter your MONTHLY household income from all sources.
PLEASE ATTACH FINANCIAL VERIFICATION

Salary/Wages $Social Security $

Unemployment/Work Comp $

Supplemental Security Income $

Social Security Disability $

Alimony/Child Support $

Social Security Retirement $ Other $

Pension/Retirement $

Total Monthly Household Income $

Please verify above information is correct.
(Signature of applicant)

Prescription Assistance Service
Rx for Oklahoma
Washita Valley Community Action Council
205 West Chickasha Avenue
P.O. Box 747
Chickasha, OK 73023
Phone: 405-224-5831 ext. 107
Fax: 405-222-4303

Release Form

The Prescription Assistance Service, Rx for Oklahoma, is designed to address the
medication needs of individuals in our commty. This program participates with
pharmaceutical manufacturers to offer assistance and provide medications to l
ow-incomeor uninsured people. These medication manufacturers often require
personal demographic, therapeutic, and financial information as part
of the application process. For your convenience, we ar requesting your
permission
to access and provide manufacturers with the requested medical and financial
information, as needed .

By signing this statement you authorize the Prescription Assistance Service to
complete any and all forms and applications on your behalf, and to access and
release any personal demographic, therapeutic, and/or financial information
relating to applications for drugs manufacturer assistance programs. This
authorization may be revoked at any time by contacting the Prescription
AssistanceService, Rx for Oklahoma at 405-224-5831 ext.107
and participating partners, The right to appeal does not
guarantee the right to modify individual pharmaceutical companies policies
and procedures.

               &nbs
              (Signature)            (Date)
__________________________________________________________

                                    Primary Physician Information:

Physician Name:    Phone:

Street Address:

City:    State: Zip:

Years with Physician:

PLEASE LIST ALL PRESCRIPTIONS. IF MEDICATION WAS PRESCRIBED
BY A DIFFERENT PHYCISIAN THAN THE ONE LISTED ABOVE CHECK "NO"
AND COMPLETE THE NEW PHYSICIAN INFORMATION.
LIST ALL ALLERGIES:

Prescription 1 Primary Physician:YES NO
PrescriptionDosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

_________________________________________________________

Prescription 2 Primary Physician:YES NO

Presription Name:Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

__________________________________________________________

Prescription 3 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 4 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 5 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

_________________________________________________________

Prescription 6 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 7 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 8 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 9 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 10 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 11 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 12 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 13 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 14 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phon

Street Address:

City: State: Zip:

___________________________________________________________

Prescription 15 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

__________________________________________________________

Prescription 16 Primary Physician:YES NO

Presription Name: Dosage:

Physician Name: Phone:

Street Address:

City: State: Zip:

If you have more medications than space available, please
ask for an additional prescriptionrm
or attach your own sheet with the requested
information.

Washita Valley Community Action Council
205 W. Chickasha Ave. Suite 5, P.O. Box 747, Chickasha, Oklahoma, 73018, US
phone: 405.224.5831 fax: 405.222.4303