Do You Qualify?
- 1. Is your organization a 501(c)(3) non-profit or government entity in the United States?
- 2. Does your organization provide health care services to people in the United States who are uninsured or underinsured, and whose income is below 300% of the federal poverty level?
- 3. Does your organization have the capacity to inventory, store and dispense donations, including prescription medications?
If you answered YES to all 3 questions, please review the information below and proceed with creating an account on the next page.
- Before you begin your application, please make sure you have the following documents at hand:
- -Medical license for medical professional with prescribing authority
- -Pharmacy license or dispensing certificate, if applicable
- -Health care facility/mental health care facility license, if applicable
The last two pages of the application require review and e-signatures of the following agreements:
- 1. Medical Professional Agreement of Responsibility
- Must be reviewed and signed by ONLY the medical professional who is authorized by the leadership of the organization to receive and distribute prescription medications on behalf of the organization and who is listed in this application.
- 2. Affiliate Partnership Agreement
- Must be reviewed and e-signed by ONLY the CEO or Executive Director of the organization listed in this application.
Please download and review the following documents before continuing: