Hello, Benefit Clubs!
Before submitting an application, please confirm all questions below are answered YES.

1. Is the applicant currently paying more than $60 a month for one medication?
2. Is the applicant currently looking for help with the cost of their prescribed medications?
3. Does the applicant fall within the income guidelines?
4. Is the applicant a legal resident of the United States?


If the applicant says yes to the above questions and falls within the income guidelines, then explain the following:


"Based on these questions, you may be eligible for the Simplefill program. Simplefill is a full-service prescription assistance program that has been helping patients who do not have adequate financial resources and limited to no prescription coverage receive help affording their medications. Simplefill does charge a fee but they guarantee it will be less then what you are currently paying or they will not enroll you into their program. There are no contracts or application fees. Simplefill is a program that only wants to help their members save on their medications. If you would like to continue, we can start an application for you now and a Simplefill representative will contact you to learn more about your situation and hopefully enroll you into their program. The team at Simplefill works fast and you will be contacted within 24 hours from the time your application is submitted. Would you like to submit an application now to see if you are eligible? "


If the caller says yes to all of this, then submit the application.

Patient Information

    First Name
    Last Name
    Phone
    Other Phone
    Mailing Street
    Mailing City
    Mailing State
    Mailing Zip
    Email
    Gender
    Marital Status
    Group Number
    Agent ID Number

Insurance

Health Insurance
Medicare
Prescribed Medicine not covered by plan?

Doctor

    First Name
    Last Name
    Phone Number

Doctor Address

    Street Address
    Street Address 2
    City
    State
    Zip/Postal Code
NamePhoneAddressAction

Prescription

    Name of Medication
    What is the dosage
    How often do you take this?
    Doctor`s Name
NameDosageFrequencyDoctorAction