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Prescription Assistance Program

In looking for ways to better serve out community the Prescription Assistance Program was established as a “courtesy to our patient” here at Holmes County Health Department. This program was developed for our patients that were having financial difficulty paying for their prescription medications.  This free service is for individuals who have no insurance coverage and are not eligible for any type of assistance with purchasing medications.  To be eligible for this program, the client must be a patient of our physician here at Holmes County Health Department, meet the program guidelines and must complete a Prescription Assistance Intake Form.  Proof of  income is required which includes supplying copies of the income such as benefits statement, pay stubs, and current year tax forms.  If there is no income in the household other forms must be completed. Medicine

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There are a  limited number patients that we can serve through the program and calls are received daily requesting to be placed on the program.  Although we might not be able to assist you at the time you call there  are alternative solutions for assistance through the RX Assist program.  Patients can access the RX Assist website and obtain the necessary forms to fill out and submit to the pharmaceutical company for help. This helpful website allows the patients to find out the qualifications and necessary paperwork required for the assistance. Simply download the form, fill out the patient portion, bring the form to the Health Department for the physician’s signature.  Once the doctor has signed and completed the physician portion, the patient can pick up the form; attach the necessary paperwork along with the prescription for a 90 day supply of medication.  Some of the medications will be sent directly to the patient's home but most medications will be sent to the physician's office and one of our staff will contact you for pickup. This process usually takes 4-6 weeks.  For more information you may contact our office and speak with our representative who will be more than happy to assist you. Prescription Meds

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RX Assist (Opens in a new window) 

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PDF-251KB (Opens in a new window)

Request for Transcript of Tax Return

PDF-54KB (Opens in a new window)

Prescription Assistance Intake Form

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Contact Info:

(850)547-8500 x249

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* These documents are in Adobe Acrobat PDF format.  If you do not have Adobe Acrobat Reader installed it may be downloaded free from Adobe.