Program Enrollment
Step 1: Please complete this information about yourself:
*
First Name:
MI:
*
Last Name:
*
Date of Birth:
(mm/dd/yyyy)
*
Gender:
Male
Female
*
Address Line 1:
Address Line 2:
*
City:
*
State:
*
Zip Code:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Phone #:
(999-999-9999)
Email Address:
How did you hear about us?
Family & Friends
Government Agency
Hospital or Clinic
Job Fair
Library
Pharmacy
Time & Temperature
TV or Print Ad
Website
Other
If under age 60, please report annual or monthly income in all applicable spaces. Please do not include dollar signs or commas. Please select whether you will be reporting monthly or annual income for all applicants.
*
Income Type:
*
Income:
*
Family Size:
*
Language:
Monthly
Annual
English
Spanish
Somali
Step 2: Enter your family members information:
Relationship:
First Name:
MI:
Last Name:
Gender:
Date of Birth:
Income:
Spouse
Child
Male
Female
Child
Male
Female
Child
Male
Female
Child
Male
Female
Step 3: Prescription Drug Coverage
No one applying for this program currently has or has had prescription drug coverage in the
last four months.
Someone applying for this program had prescription drug coverage in the
last four months
but:
The person(s) who had coverage is/are 60 or older
The company or insurer that provided drug coverage has filed for bankruptcy.
The person(s) is/are no longer eligible for coverage through a retirement plan.
The person(s) is/are no longer eligible for Medicaid,disability medical assistance or children's health insurance program.
The person(s) is/are either temporarily or permanently discharged from employement due to a business reorganization or layoff.
Step 4: Attest to this Application:
I affirm that the information on this application is true, complete and accurate to the best of my knowledge. I agree to comply with program eligibility in accordance with Ohio Revised Code § 173.76 and to notify Ohio’s Best Rx of any change in my address or family size which may affect my eligibility for the program.
If attesting on behalf of the applicant, I also affirm that I am authorized to do so.
PLEASE NOTE: Knowingly making a false statement on this application is falsification, a misdemeanor of the first degree.
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Ohio's Best Rx / Envision Pharmaceutical Services Inc. 2181 East Aurora Road Suite 201 Twinsburg, OH 44087
