Eligibility Requirements & Criteria
Please Provide the Following:
Complete the Questionnaire/Application. (Form provided)
Provide a Photo ID and Social
Security Card.
Send a current Doctor's statement with your prognosis, diagnosis.
Provide
a complete list of your current
Medications.
(Form provided)
Provide
a signed copy of your 2006 income tax return or other proof of
current income.
Provide
proof of any current government assistance that you may be
receiving.
Sign
the
Release of Information sheet.
(Form provided)
Sign
Certification with the following
disclosures: (Form provided)
a.) That applicant(s) are at least 50 years old.
b.) That applicant(s) have little or no medical coverage.
c.) That applicant(s) fall within the "Low-to-Moderate" income bracket.
d.) That applicant(s) are currently afflicted with a life threatening condition
such as High Blood Pressure, Cancer, Heart Disease, HIV/AIDS, or
Diabetes.
