Vincentian Community Pharmacy

SVdP Georgia Community Pharmacy Referral

If you have clients who you believe may qualify for service at the SVdP Georgia Community Pharmacy, please submit a Client Eligibility Application below to begin a referral. Be sure to read all the information below before submitting a referral.

If you have additional questions about the pharmacy or would like to volunteer, please contact Samantha Ricks at sricks@svdpgeorgia.org or 678-892-6181.

NOTE: We are experiencing a high referral volume, which may cause delays in our response. Please know that we working through each referral as quickly as we can. To help your referral process run smoothly, please ensure you have submitted all of the information requested on the Referral Form. **INCOMPLETE REFERRALS WILL BE DELAYED.

How to Make a Referral

Assess whether a neighbor in need requires prescription assistance during a home visit. You may find it helpful to print and use this Data Collection Form during your home visit to gather the necessary information for the pharmacy application.
Complete and submit the online referral application on the neighbor’s behalf. The pharmacy team will review the submission and contact the neighbor within 2-3 weeks.
Enter the referral into CMS. Click Here for Step by Step Instructions

FAQ

What is the SVdP Georgia Community Pharmacy?

The SVdP Georgia Community Pharmacy is a fully licensed charitable pharmacy with a mission to provide prescription medications and wellness education for those in need by providing prescribed maintenance medications to low-income individuals.

What types of medications/conditions are available?

Maintenance Medications will be available for the following conditions:

Diabetes
Cardiovascular
Mental health conditions
Chronic respiratory conditions such as asthma and COPD

With the hopes of expanding the number of clients SVdP Georgia serves, the SVdP Georgia Community Pharmacy will help uninsured adults with low incomes throughout the state of Georgia with a compassionate resource to fill current prescriptions for free or low- cost and ensure safe and effective use of medicine.

Who is eligible for a prescription?

Eligibility for pharmacy services is determined on the basis of income and expenses. The SVdP Georgia Community Pharmacy serves eligible patients with an income no greater than 200% of the federal poverty level (fpl) and uninsured individuals 18 years of age and older that live within the state of Georgia and have a valid prescription(s) for the medication needed. Once a patient submits an online prescription request form, the SVdP Georgia Community Pharmacy staff will check to confirm eligibility.

*We follow the income eligibility guidelines below as a reference when determining a neighbor’s eligibility for the program.

Are undocumented individuals eligible?

The pharmacy will assist undocumented individuals.

What client information is needed for the referral application?

View the Data Collection Form that contains all of the information you will need to obtain from your client prior to starting the referral application. You can print this out and take it on your home visit.

Data Collection Form

How do I make a CMS entry for SVdP Community Pharmacy Referrals?

CMS Entry for SVdP Community Pharmacy

client eligibility application

"*" indicates required fields

Step 1 of 2

Client Information

Name

First Middle Last

Gender

Age

Date of Birth

Home Phone

Cell Phone

Please double-check that you have entered the correct contact information. Incorrect information (along with incomplete applications) will cause a delay.

Client Email

Address

Street Address Address Line 2 City ZIP Code

County*

Mailing Address (If Different)

Street Address Address Line 2 City ZIP Code

County

Ethnicity (Select All that Apply)

Family Household Information ( Select All that Apply)

Is the client undocumented?*

Yes

Is the client underinsured?*

Does the client have insurance coverage but the limits may not be high enough to cover the full expense of medications?

Yes

Is the client uninsured?*

Yes

Prescription Assistance Eligibility

Does the client have a primary care physician?

Physician Name

First Last

Clinic

Phone

Fax Number

Caseworker Information

Caseworker Name

First Last

Caseworker Email

Caseworker Conference

Date

For questions about this application, please contact us at pharmacyapplication@svdpgeorgia.org.