FARMacy WV

Please fill out this eligibility form and someone from our team will respond back if there is a slot available.

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Your Provider's Last Name(Required)

PATIENT INFORMATION

Name(Required)
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Which chronic conditions do you have?
If you selected "none", you are ineligible for FARMacy. STOP here.
Do you currently participate in any of the following programs (or have you participated in the last 12 months?)(Required)
Do you currently have a household income of less than 185% of the Federal Poverty Level? (SEE CHART BELOW)(Required)
Please refer to the chart below for the income guidelines.
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