Rx Meds Partner :: Free & Prescription Drug Programs Made Easy!

Qualify For Free Or Reduced Costs Medications Today!

Submit this questionnaire and we will research your prescriptions at no charge. We will respond by e-mail with the results and await your decision as to whether you wish to apply. All information is required in order to complete the research. Click here for a printable version of this research questionnaire.

Please note: you must have Adobe Acrobat Reader installed on your computer to view our printable document. To install Adobe Acrobat Reader to your computer, please click on the button to the left.

1) Who are you filling out this questionnaire for?
Self:	Other:

How can we contact you?
Name:	(Required)
Address:
City:
State:
Zip:	- (Required)
E-mail:	(Required)
Phone:	(Required)

Best time to call:

2) Is applicant:	Male
	Female

3) Is the applicant a U.S. CITIZEN?
	Yes
	No

	If NO is your answer, you will not be eligible for many, if any, programs we screen for. You may continue, however, you may want to contact the Immigration Forum to determine if a person of your immigration status is eligible for any U.S. programs.

4) Which state does the applicant live in?
	Same as above

	If Not:
State:
Zip:

5) Please enter the applicants date of birth

6) What is the applicants current marital status?
	single
	married
	divorced
	widowed

7) Is the applicant a US Veteran?
	Yes
	No

8) Is the applicant eligible as a US military retiree, including retired guards and reservists, who has served 20 years or more?
	Yes
	No

9) Has the applicant been diagnosed with Alzheimer’s disease or a related disorder?
	Yes
	No

10) What is the total yearly household income on tax return or other income documents such as Social Security statements?
	$

10a) How many people live in the household? What is the source of income for each person in the household?


11) What is the household monthly expense for rent or mortgage and utilities?


12) Does the applicant currently have prescription drug insurance coverage or receive prescription benefits from another source: Medicaid, State Pharmacy Assistance or Veterans Medical? Do not include prescription discount cards as coverage.
	Yes: if yes, what does coverage pay for?
	No

13) How much money does the applicant spend each month out of pocket on medical expenses? Include healthcare not covered by insurance: cost of medical equipment and prescriptions, doctors fees, co-payments, transportation to the doctor, home health attendants, health insurance premiums, annual deductibles and nursing home expenses.
	$

14) Please list the names of all prescriptions you would like us to research. No dosage required.


15) How did you hear about our service?


Submit this questionnaire and we will call to review it with you. We may need to ask some additional questions to help decide if you may be eligible. We never ask for your credit history or Social Security number in order to determine eligibility. Call us if you have questions and we will be happy to answer them

	Click Here to check your Eligibility and availability of your medications
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©2007 Rx Meds Partner
RX MEDS PARTNER is not affiliated in any way with pharmaceutical companies. We do not receive any payment from any company, only from the consumer/patient. We cannot guarantee eligibility until each company has reviewed your application and replied with a decision. Doctor's participation and prescription is required for each application. Identification and documents such as proof of income and U.S. citizenship may be needed for each application if you decide to apply for free prescriptions or other benefits.