Consent Form (PDF) | Available Drugs
Cooper Green patients who are having trouble paying for their medications can get them at no charge through the Prescription Assistance Program (PAP). To apply for the program, patients must first fill out a PAP consent form, which is available at the front desk of each Cooper Green clinic.
One you’ve filled out the consent form, visit Room 105 on the first floor of Cooper Green and give the completed form to a staff member there or leave it in the PAP drop box outside the room. The form gives permission for a Cooper Green patient service coordinator to apply for the program on your behalf. Patient service coordinators are available to accept your completed form in person Monday through Friday from 8 am-noon and 1 pm-4 pm.
The consent form must be submitted with proof of your income, even if you do not have income. Any one of the following documents can be used as proof of income:
- Social security award verification letter from the current year or last year
- Your last two paycheck stubs
- Tax return or W-2 forms
Patients who are approved for the program will pick up their medication at Cooper Green after showing proof of identification. Some medications, such as inhalers, can be mailed to you. Medications that are waiting to be picked up for over 30 business days (Monday through Friday, not including holidays) will be discarded or returned to the drug company. You must have a valid prescription from a Cooper Green provider to receive medications through the Prescription Assistance Program.
When it’s time for a refill, please contact the PAP voicemail line at (205) 930-3570 and leave a message about the medication you need. To reach a patient service coordinator about prescription assistance, please contact (205) 930-3203. You can also email our patient service coordinators at email@example.com.