Patient Eligibility Requirements

Current patients: to renew your application, please click below.

New patients: scroll down to read qualifications for service and how to apply.

Patient Eligibility Requirements

Current patients: to re-submit your application, please click below.

New patients: scroll down to read qualifications for service and how to apply.

Qualifications for Service

  • You must be a resident of the state of Texas,

  • have an annual household income below 300% of the Federal Poverty level for your family’s size,

  • have no health insurance, and

  • have a valid prescription for your medication.

pharmacist's hand holding pill bottle
volunteer woman smiling

To Apply

  • Fill out the application

    • Type your answers into the fillable PDF, then save the document to your computer

    • You may also download and print the application to complete by hand.

  •  Gather all your documentation:

    • Proof of residence

    • Proof of income
      If you have no income, or someone helps to support you, you can submit the Hardship Referral Letter to meet the proof of income requirement.

    • photo ID

    • Prescription

  • Due to COVID-19, all applications and documentation must be scanned and emailed to either rchavez@svdpdallas.org or gloredo@svdpdallas.org

 

Services Provided

  • No cost for your prescription medications

  • Medication counseling

  • Blood pressure checks

  • Refill reminders

  • Delivery assistance:
    • Potential delivery of medications to clinics
    • Mail order delivery
pill bottle with prescription label
pharmacist's hand holding pill bottle

Qualifications for Service

  • You must be a resident of the state of Texas,
  • have an annual household income below 200% of the Federal Poverty level for your family’s size,
  • have no health insurance, and
  • have a valid prescription for your medication.
volunteer woman smiling

To Apply

  • Fill out the application
    • Type your answers into the fillable PDF, then save the document to your computer
    • You may also download and print out the application to complete by hand.
  •  Gather all your documentation
    • Proof of residence
    • Proof of income
    • photo ID
    • Prescription
  • Due to COVID-19, all applications and documentation must be scanned and emailed to either rchavez@svdpdallas.org or gloredo@svdpdallas.org

Scroll down to submit your application.

Services Provided

  • No cost for your prescription medications
  • Medication counseling
  • Blood pressure checks
  • Refill reminders
  • Patient Assistance Program enrollment
  • Delivery assistance:
    • Potential delivery of medications to clinics
    • Mail order delivery

Submit Your Application

If you are a new patient, click on the button below, and fill out the entire form. Once you have finished, save the file to your computer. Then, please email your application and documentation to: rchavez@svdpdallas.org or gloredo@svdpdallas.org.

DON’T FORGET to also attach your documentation. Remember that if you have no income or someone supports you, to complete the Hardship Referral Letter.

Have questions about your application? Not sure whether you qualify?

Call Us Today. We’re happy to help!

  

 

469-232-9902