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| | Option A Recommended Faster Option Save on Postage and Save Time Click Here to Apply Online Now Option B | | | 1. DOWNLOAD and print the Medicine Information Form below.
2. COMPLETE the form:
 Fill in your name, address and the telephone number
Fill in the name of the medicine that are currently taking
Write the name and address of the doctor
Enclose a fully refundable* one-time processing fee of $5 for EACH medication (For example: If you are requesting 3 medicines, please enclose $15) We accept cash, personal checks and money orders
3. SEND the completed Medicine Information Form along with an a processing fee to the following address:
Free Medicine Program
PO Box 630217
Miami, FL 33163-0217
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Medicine Information Form | Click here to download the Form. | | | To get Adobe Reader - "Click" "Get Acrobat" image. There is no fee to install this on your computer. This is a free application. |  | | | * Subject to terms and conditions of our Guarantee.
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| | "The application process was simple and fast"... Michael D., NewJersey "Way to Go! Glad to see others helping those in need..." Mary H., Executive Director Walker County Housing Authority Huntsville, TX | | | | |
