Intake Form | Wecare

WeCare Intake Form: Applicant Profile

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First name (Applicant)

Last name

D.O.B required

Last 4# of SS#

Street Address

City

Region/State/Province

Street Address Line 2

Different Mailing Address

Postal / Zip code

Mailing Street Address

City

Region/State/Province

Street Address Line 2

Postal / Zip code

Phone

Other

First name (Spouse)

Last name (Spouse)

D.O.B (Spouse) required

Pre-Qualification Questionnaire

Number of Person (s) living in your houusehold

Number of Person (s) appling for Assistance

Applicant's Total Income

Total Income of all Other Household Members

Total Income from Wages and all other sources

I hereby affirm that the annual household and income information provided above is accurate and truthful to the best of my knowledge.

Please list other assistance Program

Name of your insurance carrier

I hereby attest that I am not covered by any form of prescription insurance, nor am I covered by any form of government-sponsored health insurance, including Medicare, Medicaid, VA benefits, or other coverage.

Provide copy of valid perscription

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Name of primary care provider (PCP)

PCP Practice Name

PCP Phone #

By clicking the box you agree to allow our providers to bill any other insurance or third-party payer who may be responsible for all or part of the individual’s prescription expenses.

Please provide income verification for your entire household, including any income earned by dependents, for the 3 months or 90 days prior to your application (whichever is greater).

Income verification document

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Additional financial documents

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Release of Information – Agent Authorization form: If you want another person to discuss your application, including medical and/or financial information, include the Agent Authorization form (for example, power of attorney, healthcare surrogate form, order, appointment of a guardianship, order appointing personal representative, letters of administration).

Agent Authorization Form

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Please let us know if there is any additional information you would like to share about your application.

I was referred by: (Please list Name and Agency if applicable)

I certify that all of the above information is true and accurate. I understand that WeCare Pharmacy and its third-party partners will utilize this information is to be used to determine eligibility services. I will notify staff of any changes in employment, income or insurance prior to having additional prescriptions filled. "I understand that the information I submit is subject to verification by WeCare Pharmacy and its agents. I understand this application may be denied if the request does not meet WeCare criteria.

Your Signature

Thank you for applying to WeCare Pharmacy for assistance with your prescription medication. You can expect to hear back from one of our representatives within 3-5 business days regarding the status of your application. If you have any questions, please don't hesitate to contact us at info@wecarepharmacy.org

Dear applicant, WeCare may be able to offer assistance with the costs of your prescription medication through one of our participating pharmacies. Please note that each applicant will need to complete a separate application.

We Care Pharmacy

WeCare Intake Form: Applicant Profile

Pre-Qualification Questionnaire

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