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 a provider. Physicians can e-scribe prescriptions to the pharmacy or fax to 704-536-9812. Transfers are not accepted.
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 married and your spouse is not currently working, your spuse 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. Letter of Support- English or 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.
- 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
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.
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.