Required Enrollment Information

In order to process your clients application for assistance, please complete the following information and submit to us.




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Medications They Need Assistance With


Membership Information

Agent Information

Upon Submission of This Form Your Client Will Be Billed A One Time Non Refundable Application Fee of $25.00. 
 
Their Next Scheduled Payment Date For Their Monthly Membership Fee Will Be Based On The Date Selected Above Two Months After Submitting THis Enrollment. 
 
Example: Today is January 15th and they wish to have their monthly membership fee deducted on the 22nd of every month. On submission of this form they will be billed the Application Fee of $25.00. Their reguarly monthly membership fee will not be processed until March 22nd.