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What We Do / Providing access to healthcare

SVdP Georgia Community Pharmacy Eligibility & Request Form

Who Is Eligible

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.

HOUSEHOLD SIZE/MONTHLY INCOME CHART

Use this chart to determine if you are eligible for SVdP Georgia Community Pharmacy services. For questions regarding your eligibility, contact pharmacyapplication@svdpgeorgia.org.

FILLING OUT AN APPLICATION IS QUICK & EASY

Please fill out the form below and our pharmacy team will be in touch!

Note: We are experiencing a high volume of applicants, which may cause delays in our response. Please know that we are working through each application as quickly as we can. To help your process run smoothly, please ensure you have submitted all of the information requested.

"*" indicates required fields

Step 1 of 4

25%

DOCUMENTS NEEDED FOR CERTIFICATION

Photo ID

Proof of current address

Verification of your income and the income of all members of your household, including:

Two most recent paychecks or pay stubs; AND/OR

Unemployment Benefit Statement; AND/OR

Statement of Social Security, SSDI, or SSI income; AND/OR

Statement of Child Support and/or Alimony; AND/OR

Latest tax return; AND/OR

Any other source of income with dollar amount received

If you have no income, please upload:

Letter from the health agency or case manager of the social service agency that referred you, on agency letterhead, stating that you have no income or health insurance

Letter from anyone who gives you money to pay your bills stating that you have no income or health insurance

Your total household monthly gross income must be at or below 200% FPL for participation in this program. (PLEASE REFER TO HOUSEHOLD SIZE/MONTHLY INCOME CHART)

File Upload

Drop files here or

Max. file size: 50 MB.

Name of Applicant

First Last

Applicant Email

Date

MM slash DD slash YYYY

Name of Parent or Guardian (if applicant is under 18)

First Last

Gender

Age

Date of Birth

Month

Day

Year

Home Phone

Cell Phone

Address

Street Address Address Line 2 City ZIP Code

County

Ethnicity (Select All that Apply)

IT IS YOUR RESPONSIBILTY TO PROVIDE: CURRENT PROOF OF INCOME AND RESIDENCY. IF YOU DO NOT PRODUCE SUCH DOCUMENTS YOU WILL NOT BE ELIGIBLE FOR SERVICES. I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.*

I agree

IT IS YOUR RESPONSIBILTY TO PROVIDE:
CURRENT PROOF OF INCOME AND RESIDENCY. IF YOU DO NOT PRODUCE SUCH DOCUMENTS YOU WILL NOT BE ELIGIBLE FOR SERVICES. I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Total number of people in household:

Total monthly gross household income (all members)

Do you have Insurance?

Do you have a primary care physician?

Physician Name

First Last

Clinic

Phone

Fax Number

I acknowledge that the information concerning income has been explained to me and that I understand it. I also understand that I 'have been certified for the time period listed above. I understand that all new and refill prescriptions may be dispensed in non-child resistant containers. Permission for Patient Assistance Program Review of Patient Records: I attest to the above information as true to the best of my knowledge and will report any changes of my insurance status or income to St. Vincent de Paul immediately. I hereby authorize St. Vincent de Paul to share any of my information, including prescription records, with any Patient Assistance Program(s) for which I qualify, or the Program designee(s), in order to coordinate services, and/or for internal auditing purposes. I understand that I may revoke this consent at anytime by contacting St. Vincent de Paul except when action has already been taken to obtain and/or release such information. My signature on this release indicates that I have read the above, or have had it read to me, and that I understand the terms and conditions. I have also had the opportunity to ask any questions. If applicable, I am also signing this release on behalf ofmy children that are under the age of eighteen (18). I understand that ifl wish to revoke this consent, I must do so in writing. In order to access Bulk Replacement Programs each patient must be the signer of their own application.*

I agree*

I acknowledge that the information concerning income has been explained to me and that I understand it. I also understand that I
'have been certified for the time period listed above. I understand that all new and refill prescriptions may be dispensed in non-child resistant containers.

Permission for Patient Assistance Program Review of Patient Records:
I attest to the above information as true to the best of my knowledge and will report any changes of my insurance status or income to St. Vincent de Paul immediately. I hereby authorize St. Vincent de Paul to share any of my information, including
prescription records, with any Patient Assistance Program(s) for which I qualify, or the Program designee(s), in order to
coordinate services, and/or for internal auditing purposes.

I understand that I may revoke this consent at anytime by contacting St. Vincent de Paul except when action has already been taken to obtain and/or release such information. My signature on this release indicates that I have read the above, or have had it read to me, and that I understand the terms and conditions. I have also had the opportunity to ask any questions. If applicable, I am also signing this release on behalf ofmy children that are under the age of eighteen (18). I understand that ifl wish to revoke this consent, I must do so in writing.

In order to access Bulk Replacement Programs each patient must be the signer of their own application.

Name (If submitting on behalf of applicant)

First Last

Please list all prescriptions that the patient needs below:

Please list all prescriptions needed below

Encounter (N/T/R/E)

Drug Name & Strength

Prescription #

Pharmacy Name

Pharmacy Phone

Click the + symbol to the right to add additional names.

Please list all Allergies:

Comments/Referral (Please list any additional medications here)

CONTACT US

Contact the St. Vincent de Paul Georgia Community Pharmacy at pharmacyapplication@svdpgeorgia.org. To submit an application, fill out the form above.

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Mission

To serve our neighbors with love and respect: delivering help, hope, and pathways to self-sufficiency.

Location & Hours

2050-C Chamblee Tucker Road
Atlanta, GA 30341

Monday - Friday:
8:30 AM – 4:00 PM

Contact

Main: (678) 892-6160

Assistance: (678) 892-6163

Pharmacy: (770) 687-2610

info@svdpgeorgia.org

Donations: gifts@svdpgeorgia.org

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