Rx Outreach

We're now providing secure access to your account information via the internet (click here)

Complete the enrollment form to see if you qualify for hundreds in savings and register to be eligible for 3 months of free medication.

First Name: Last Name:

The full names of selected individuals will not be shown publicly

Address:

The content of this field is kept private and will not be shown publicly

City: State: Zip:

The content of this field is kept private and will not be shown publicly

Gender: Phone: Email (optional):
The content of this field is kept private and will not be shown publicly

Annual Income:

Number in household, including you:

The content of this field is kept private and will not be shown publicly

Date of Birth:

Social Security Number (optional):

List Allergies (optional):

Please list all medicines you currently are taking:

In 200 words or less tell us why you are in need of financial relief:

Signature:

Enrollment forms must be submitted by October 21, 2011. Individuals will be selected by October 28, 2011.

Over 400 medications are available. See if your medications are on our list.

Rx Outreach can save you money on prescriptions today. You can take advantage by submitting the enrollment form. If you meet the income guidelines, you will be enrolled at no cost to you automatically. If you choose to order medications now and are selected for 3 months of medication, any fees paid will be refunded to you. Free medications on the offering are limited to those drugs that are on the Rx Outreach program.

By submitting this form you attest that the information provided in this enrollment form is complete and accurate.

Rx Outreach® – A non profit organization