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Application Form

Thank you for reaching out to Helprx.org. We are here to help uninsured and low-income individuals access the medications they need at a minimal cost. Please fill out the application below to determine your eligibility for our program.

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Personal information

First Name

Family Name

Date of Birth

Address

City

State

Zip Code

Email

Phone Number

Financial Information

Do you currently have health insurance?

Do you currently have health insurance?

Yes No

Do you receive medication subsidies from any other organizations or government programs?

Do you receive medication subsidies from any other organizations or government programs?

Yes No

Estimated Monthly Income

Number of Dependents

Medical Information

Chronic Condition(s) Requiring Medication:

Chronic Condition(s) Requiring Medication:

Prescription Information:

Please upload your prescription or schedule a free appointment with our in-house doctor.

Prescription

I don’t have prescription

I don’t have prescription

Medications

Medication Name

Mg Selection

Pills selection

Monthly cost

Medication 2

Add more

Medication Name

Mg Selection

Pills selection

Monthly cost

Medication 3

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Medication Name

Mg Selection

Pills selection

Monthly cost

Medication 4

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Medication Name

Mg Selection

Pills selection

Monthly cost

Medication 5

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Medication Name

Mg Selection

Pills selection

Monthly cost