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Program Information

Please complete all the information on this form so we can enter your program into our database.

Program Name  Address Line  Address Line  City, State and ZIP     Local Phone  Toll Free Phone  Fax  E-mail  Website  Hours/Days of Service  Who You Help (Be specific)  How You Help (Be specific)  Geographic Area Serviced  Services You Provide  Eligibility Criteria  How to Apply  Is your organization non-profit?  Non-ProfitFor-Profit Do you charge a fee?  YesNo If yes, how much? Languages  This following information is for our files only and will not appear on the website Please check one or more of these descriptions to help us categorize your program:   This program or foundation is based on a specific disease, assists patients with health-related expenses (including financial grants, insurance copays, purchase of some health-related goods or other assistance with expenses)   This program helps patients find and apply for Patient Assistance Programs and other types of assistance.   This program is funded and administered by the state.   This is a Free Clinic that provides direct medical, dental or mental health services at little or no charge or on a predefined sliding scale. Contact Person  Position/Title  Contact's Phone  Contact's Fax  Contact's Email  Contact's Address (if different from above)  Other Comments    Copyright ©2010 by NeedyMeds, Inc. Contents may not be reproduced in any form except for personal use and may not be used on any other website without permission.