Good Samaritan Pharmacy & Health Services, Inc.
  • Our Mission
  • About Us
  • Our Services
  • Volunteers
  • Apply Now
  • Contact Us
Good Samaritan Pharmacy & Health Services, Inc.
  • Our Mission
  • About Us
  • Our Services
  • Volunteers
  • Apply Now
  • Contact Us

To APPLY:


  • Clients need to be a legal resident and have a photo ID.
  • Clients must have no medication or prescription insurance.
  • Client must have proof of income.  Proof of income may include: Last 4 weeks pay stubs, Social Security Benefits letter, Zero Income Letter and Letter of Support, etc. (volunteer advocates can assist in getting these forms if needed). 
  • Copy of latest tax return or non-filing letter.


  • To qualify patients should be uninsured and have income of no more than 200% of the Federal Poverty Level:

  To qualify for our services, you must have NO insurance coverage, have a Valid Photo ID and have an income of level of 200% or lower of the Federal 

FORMS:

Application Packet 2022 (doc)Download
Health History Form 2022 (docx)Download
Letter of Support 2022 (docx)Download
Zero Income Letter 2022 (docx)Download
IRS Non-Filing Form 2022 (pdf)Download

Copyright © 2022 Good Samaritan Pharmacy & Health Services, Inc. - All Rights Reserved.

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