Medication Assistance Program Application

  • There is NO application fee and all medications received from Welvista are completely FREE.
  • Medications are mailed by US Postal Service to the patient’s home.
  • Applications are active for one year, unless the patient receives health insurance during that time.

You MUST print, sign and date the application before sending it in; Your application and supporting documents can be mailed, emailed or faxed to us.

Application Packet

Employer Statement of Income Form

No Household Income Form

Attestation of Physical Address/Patient Identification Form

Forms in Spanish

Pacquete de Solicitud

DeclaraciĆ³n de Ingresos del Empleador

Formulario de Ingresos Nulos

Preguntas Frecuentes

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If you are seeking information on your application status or are a patient with questions about your prescription(s), please call us at 803-933-9183.