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Our goal is to provide resources and assistance that foster a stronger, more connected community.

Prescription Assistance Program

Apply For Our Financial Assistance Program for Elderly Citizens of Cuyahoga County

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

Address

Statement of Financial Need

Please provide a brief description of your current financial situation to help us better understand your need for assistance and determine how we can best support you.

Do you agree to submit a reciept after obtaining needed medications?

Yes

Thank you for applying to our Financial Assistance Program for Elderly Citizens of Cuyahoga County. We are committed to providing support to those in need and will carefully review your application to ensure you receive the assistance you deserve. If you have any questions or need help completing the form, please don’t hesitate to contact us. Your well-being is important to us, and we’re here to help you through this process.