Prescription Assistance

Online Application

To apply for the Prescription Assistance Program, please complete the below online application. You must be a South Dakota resident to apply. It is very important to be as specific as possible when completing this application. When listing the physician information, use the physician's first and last name, clinic name and street address. PO Boxes are not accepted. Incomplete applications will delay processing.

Personal Information
First Name:
Last Name:
Address:
City:
State:
Note: You must be a SD resident to apply.
Zip Code:
Phone Number:
Email Address:
Date of Birth:
Social Security Number:
Sex:
Marital Status:
Number of individuals in household:  (include children and yourself.)
Do you receive Medicare Part A, B, or D Benefits?
Financial Information
Gross Yearly Household Income:
List where you receive your income (include spouse's income) as well as the $ amounts:
Social Security:
Social Security Disability:
Unemployment:
Wages:
Other:
Savings/Checking/CD Balance:
Eligibility Criteria:
Minimum: You must be a South Dakota resident
Income Guidelines:
Single Person = $18,000 yearly; Couple = $24,000 yearly
Asset Guidelines: Single Person = $8,000; Couple = $12,000
Medications
For each medication you take, list the name, dosage (mg.), how often you take it, form of the medication, why you are taking it, and how long you have taken it.

Example: Pepcid, 20 mg., once a day, tablet, ulcers, 2 years
Physician Information
Physician's First and Last Name:
Clinic:
Address:
City:
State:
Zip Code:
Phone Number:
I authorize any health professional to release to the Prescription Assistance program, any information with respect to myself that may be related to the Prescription Assistance application, including any relevant review of drug therapy. I declare and affirm under the penalties of perjury that this information has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.
Signature:
Today's Date:
Application Assistance
If you are assisting someone with the completion of this application, please list your name, address and telephone number below.
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone Number:
Please Note: Not all drug products are covered by an assistance program. However, if you complete this application, we may be able to acquire some applications to assist you. The patient assistance programs are governed by the drug companies and are beyond the control of the Department of Social Services. We cannot guarantee you will receive every medication that is applied for or meet eligibility requirements for all companies. The Prescription Assistance Program does not purchase medications for you; we assist you in gaining access to patient assistance programs sponsored by drug companies.