Prescription Assistance Form

Prescription Assistance Program helps Chenango County residents to get medicines they need for long term if they are uninsured and cannot afford to buy their prescription drugs. The program also helps people who have Medicare Part D coverage when they cannot afford their medicines.

Pharmaceutical manufacturer companies offer free medicines to individuals who do not have prescription insurance and who meet specific guidelines established by the company. Individuals must complete and submit applications directly to the manufacturer to be considered for free medicines. Chenango Health Network helps individuals to navigate this complex system by completing and submitting applications on their behalf to the appropriate company.

Individuals can request help from Chenango Health Network by calling the agency to discuss their needs. Individuals who request CHN assistance must complete and sign a CHN application which contains their personal information required by the pharmaceutical manufacturers and which authorizes CHN to act on their behalf. Services provided are free and confidential.

Pharmaceutical manufacturers determine whether to send a medicine to the individual’s home or to their health care provider. Individuals are responsible for retrieving medicines from their provider’s office.

When a person is not eligible for a pharmaceutical manufacturer program or if a medicine is not offered, CHN staff will explore other options such as pharmaceutical mail order programs designed for low income persons in need of reduced-cost medicines. Staff will assist clients with completing and submitting applications to these companies. Staff also offers cards for discount medicine programs available through Price Chopper, Walmart and FamilyWize.

For more information please contact Alyson Hicks, Community Health Advocate.

Phone: 607-337-4105 or Email: alyson@chenangohealth.org