Download and Print the application

Please complete the online application below and click submit.

After reviewing your application, a Free Medicines Online / MED-ASSIST staff member will contact you to not only let you know which medications are currently covered, but also how much money you can possibly save each month.

In order to ensure an accurate result, please fill in all fields.

If you prefer, you can click here and download the application in pdf format. Once you have printed and completed the application, please mail it to:

P.O. Box 96
Duplessis, LA 70728
Name:
Address:

City:

State:

Zip:

Date of Birth:
Gender: Male
 Female

Home Phone #:

Email Address:
Are you a United States Citizen: Yes
 No
Marital Status: Married
Single
Widowed
Divorced
Number of people in household including yourself: 1
 2
 3
 4
 5
Did you file a tax return last year: Yes
 No
If no, Why not
Income Sources/Amounts for Total Household:
You
Spouse
Other
Social Security
Pension
Salary/Wages
Other income
Are you married and earn more than $27,000 per year: Yes
 No
Are you single and earn more than $20,000 per year: Yes
 No
* Income level requirements vary depending on each pharmaceutical company and on # of dependents per household*
Do you have Medicare A: Yes
 No
Do you have Medicare B: Yes
 No
Do you have a Medicare supplemental insurance policy: Yes
 No
Do you have Medicaid: Yes
 No
Other Insurance:
Do you buy your medications: Yes
 No
If yes, total monthly Cost:
Pharmacy Name:
List your Primary Care Doctor's name:
List your Primary Care Doctor's phone number:
Please list medications, strength, and quantity per day:
1
2
3
4
5
6
7
8
9
10
11
12
Please list medical conditions:
Medical Allergies:
Message:
*By clicking the checkboxes next to each statement below you acknowledge your agreement with the statement
I understand that I may have to provide financial information as well as health insurance cards in order to complete the application process.
I understand that it may take 6–8 weeks to initially receive my medications after my applications are finalized.
I understand that Med-Assist may need to contact me, my caregiver/family, my doctor or my pharmacy for additional information to complete the application process, and I give Free Medicines Online / MED-ASSIST permission to do so as long as I am using the Free Medicines Online / MED-ASSIST service.
Checking this box and entering your full, legal name In the field provided below serves as your signature to the above statements.
Full Legal Name of Client:
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