How to Enroll

 

Please submit an application and supporting documents. Applications missing documents are considered incomplete and cannot be processed until all information is received. If you would like to download our application checklist to assist you with enrollment, click here

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

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

2. Proof of Residency: 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.
  • If you are 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.
  • If you are currently unemployed with no source of income and does not have someone to support them financially, complete the following document: English or 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.
  • Applicants and/or spouses that do not file taxes must complete the 4506-T form. Click to download the 4506T.
  • If you are self-employed, please attach the Schedule C 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

You do not have to be a member of a partner agency to enroll. If you are interested in enrolling with a partner or do not have a doctor, 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 in the Free Pharmacy program to receive your medication from NC MedAssist.

If there is no partner agency in your county, please follow the steps to complete your 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. Doctors can also e-scribe or fax prescriptions directly to the pharmacy at 704-536-9812.