MAP (Medication Assistance Program)

Gabby 276.688.0441 Case Worker
Krista 276.688.2607 Case Worker

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

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.  

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


The forms are in  Adobe PDF format (right click, save target as - to download to your computer)

Map Patient Application

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




The above forms require Adobe Reader.

Download Adobe Reader