APPLICATION FORM
IMPORTANT! - WE CANNOT BEGIN PROCESSING YOUR APPLICATION UNTIL YOUR FEE IS RECEIVED AND PROCESSED.

Online Processing (5-7 business days): 1. Fill out all fields below (put N/A in any fields that do not apply) 2. Verify all medications are listed in shopping cart 3. Confirm that you have 3, 6, or 12 month supply 4. Hit process 5. Process payment online via PayPal	Mail Processing (7-14 business days): 1. Fill out all fields below (put N/A in any fields that do not apply) 2. Verify all medications are listed in shopping cart 3. Confirm that you have 3, 6, or 12 month supply 4. Hit print 5. Mail check or money order to: FreeMedsPlus.com LLC Po Box 67901 Phoenix AZ 85082 Note Applications will not be processed until payment has cleared.
Phone Processing (5-7 business days): Call 1-888-NoPayRx 1-888-667-2979 Note: must be able to make payment over phone

Note: Please be sure to have all necessary information before filling out fields. For your security, information will not be saved when you leave this page.

STEP 1:

Name (First, MI, Last)

Street Address (no PO Box)

City, State, Zip

Phone (XXX-XXX-XXXX)

Birthdate (mm/dd/yyyy)

Sex

Marital Status

Disabled?

Veteran?

Private Medical Insurance?

If yes, does it cover prescriptions?

Medicare?

If yes, does it cover prescriptions?

Medicaid?

If yes, does it cover prescriptions?

Medicare Discount Card?

Other Meds Assistance?

If yes, explain:

Income Information (Please list gross monthly amounts. Include all those who contribute to and/or depend on you income, including yourself)

What is your Monthly Income?

Payment method:

This is my fist time using your services, so I am including my annual $40 enrollment fee.

Prescription Information
	$40 Annual Enrollment Fee

	Prescription	Dose	Supply	Total (Supply X $8 )
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IMPORTANT! - WE CANNOT BEGIN PROCESSING YOUR APPLICATION UNTIL YOUR FEE IS RECEIVED AND PROCESSED.