How to Enroll

We are here to help with your medication needs. To enroll, please submit an application and supporting documents. Applications missing documents are considered incomplete and cannot be approved until all information is received. See below for a list of supporting documents.

 

Choose your way to apply! Send us your application or apply online today!

Send us a paper application. Scroll down to download or call us at 866-331-1348 to request an application.

 

To download our application checklist to assist you with enrollment or check our medication list, click below.

APPLICATION CHECK LIST        VIEW A LIST OF OUR MEDICATIONS

 

Before you get started, please make sure you have the following documents in order to complete your application.  For more information, click on the checklist button above.

  • Current proof of your income if you have an income
  • Current year tax return if you file taxes
  • Proof of your address

You do not have to file taxes or have an income in order to qualify.

You can enroll even if you don’t have a prescription yet! When you need a prescription filled, please have your doctor e-scribe or fax it directly to the pharmacy at 704-536-9812. Original prescriptions must be mailed. Patients cannot fax prescriptions.

Get started and apply online today!

APPLY NOW

 

Submit your paper application and supporting documents via fax or mail:

Fax applications to 704.536.9865

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

Submit Supporting Documents

A prescription is not required to apply, but in order to receive medications, we must have a current, original prescription signed by a provider. Physicians can e-scribe prescriptions to the pharmacy or fax to 704-536-9812. Transfers are not accepted.

If you already applied and need to submit your missing supporting documents, click below to upload them online:

SUBMIT SUPPORTING DOCUMENTS

 

1. Completed application:
Download the English Application or the Spanish Application.

2. Proof of Address:
Please submit one of the following: Driver’s License, Utility Bill, Phone Bill, Lease Agreement, Food Stamp Letter or any government-issued statement.

3. Proof of Income or No 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). If you cannot obtain check stubs, please have your employer complete the following document: Income Verification Form.
  • Social Security Disability “Notice of Award” letter and current year statement.
  • A current year statement if patient receives the following: retirement, pension, VA benefits, workers comp of short term disability.
  • If you are working, but paid in cash, complete the following document: Self-Employment Form- English or Self-Employment Form-Spanish.
  • If you are married and your spouse is not currently working, your spouse must complete the top portion of the following form: Zero Income Statement.
  • If you are not working with no source of income, provide a letter of support signed by the person providing room and board and/or financial support. Zero Income Statement/Letter of Support – English or Zero Income Statement/Letter of Support – Spanish.
  • If you are currently homeless with no support, please complete the Homeless Verification Form – English or Homeless Verification- Spanish.
  • If you currently live in a shelter or are part of a residential program, please provide a letter from shelter or residence.

4. Proof of tax filing or non-filing for the current year:

  • Applicants and/or spouses that file taxes must submit a 1040 for the current year.
  • If you and/or your spouse does not file taxes, please indicate that on your application.
  • If you are self-employed or receive other taxable income, please attach the Schedule 1, C, D, E, F or SE form along with your tax return.

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-4:00 PM.

Residents who live outside of Mecklenburg County

Please follow the steps to complete your application. If you have questions or need more information, you can speak with a social worker by calling us toll free at 1.866.331.1348. A member of our team will be happy to assist you with your enrollment.