The Medication Assistance Program is designed to help those without ANY
prescription drug coverage who cannot afford to purchase their medications.  

If you have ANY prescription drug coverage you are not eligible for this program. 

Therefore even if you have a policy that covers only a portion
of your medication and you are left with a co-payment,
you do not qualify for this program.

For those who do qualify for Medication Assistance, the forms below are needed.

These forms include a Sign Up Letter that explains eligibility for the program,
as well as a -2- page Patient Application that must be filled out and returned to BCMC.
A Patient Guidelines form is also included.  All -3- forms are needed. 

There is no charge for the medicine. (Subject to Drug Company eligibility requirements)
 

Here are the FORMS that are required for the Medication Assistance Program.

The forms are in Microsoft WORD format, and in Adobe Reader PDF

(right click, save target as - to download to your computer)

Print documents, fill out, and submit in person to BCMC.
 

revised 6/1/08