How to Enroll

 

How to Enroll into the Free Pharmacy Program:

 

Gather the following documents 

Applications missing these documents are considered incomplete and cannot be processed until all information is received.

1. Completed application: Click to download the English Application. Click to download the Spanish Application

2. A current prescription signed by the patient’s physician. Transfers not accepted.

3. Proof of Residency: Driver’s License, Utility Bill, Phone Bill, Lease Agreement Food Stamp Letter or any government issued statement.

4. Documents supporting proof of income – the following are examples of acceptable documentation:

  • A month’s worth of consecutive pay stubs dated within the last 60 days for the entire household (four pay stubs if paid weekly, two pay stubs if paid bi-weekly, etc). 
  • Social Security Disability “Notice of Award” letter and current year statement.
  • If the patient is currently unemployed with no source of income, provide a letter of support signed by the person providing financial support and/or room and board.  English Support Letter or Spanish Support Letter.Social Security Disability “Notice of Award” letter and current year statement.
  • If the patient is currently unemployed with no source of income and does not have someone supporting them financially, they can complete the attached document.

 5. Tax Return(s) for the current year; include Schedule C if self-employed. Patients that do not file taxes must complete the 4506-T form. Click to download the 4506T.

 

Mecklenburg County Residents

Residents in Mecklenburg County, can schedule an eligibility interview in the Charlotte office. Please call 704.536.1790 for more information or to schedule an appointment. We also accept walk-ins Monday-Friday 8:00AM-4:30 PM.

 

Residents who live outside of Mecklenburg County

You do not have to be a member of a partner agency to enroll. If you are interested in enrolling with a partner, there may be one available in your county. Click here for a list of partner agencies in your county. Partner agencies may be able to help with the enrollment process.  If you are a patient at one of these agencies, ask how you can enroll into the Free Pharmacy program to receive your medication from NC MedAssist.

 

If there is no partner agency in your county, please print and complete the English Application or Spanish Application. Please call toll free 1.866.331.1348 for more information or to speak with a social worker that can assist you with enrollment.

 

How to submit applications

Fax applications to 704.536.9865 

OR Mail applications to NC MedAssist, 4428 Taggart Creek Road, Suite 101, Charlotte, NC 28208. 

Patients cannot fax prescriptions. Original prescriptions must be mailed or your doctor can e-scribe or fax your prescription directly to the pharmacy at 704-536-9812.