Delaware Prescription Assistance Program - A prescription for better health

The Delaware Prescription Assistance Program may help you pay for your 
prescriptions if you are a resident of Delaware and:
Age 65 or over OR
Under age 65, but receiving Social Security Disability benefits AND
Have income under 200% of the Federal Poverty level or
Have a yearly drug cost of more than 40% of you income.
Enrolled in a Medicare Prescription Drug Plan (if you have Medicare)

The program will pay up to $3000 per person each benefit year. Co-pays are 25% 
or a minimum of $5.00. We do not offer or pay for mail order drugs.

You are not eligible if you: 
Are eligible for full Medicaid benefits, or 
Have a health insurance policy, other than a Medicare Prescription Drug Plan, 
that gives you prescription drug coverage.

To apply, you must send us a completed application form (below) and copies of 
the following items:
Proof of income (check stubs, award letters)
If not a citizen of the USA, proof of lawful resident status
Proof of disability, if under age 65
If eligible for Medicare, you must enroll with a Medicare Prescription Drug Plan 
and show proof of enrollment. 
If you may be eligible for the extra help, you must apply with Social Security 
and show proof of approval or denial.

For more information, call the DPAP customer service representatives
Monday through Friday
From 8:00 a.m. to 4:30 p.m.
1-800-996-9969 (Option #2)

Return original completed application and additional documents to:

EDS DPAP
P.O. Box 950
New Castle, DE
19720-0950


Please complete and sign this Application form and return it using the self-
addressed envelope. Your eligibility for this program cannot be determined 
unless your application is signed and copies of all documents requested are 
attached.

1. Applicant Name/Address
First Name MI Last Name
Social Security Number
Date of Birth
Street
Apt.
City
Zip
County  N K S
Phone Number

Race (optional)
Black/African American 
White
Hispanic 
Asian 
Other

Sex
Male
Female

Marital Status
Married 
Divorced
Widowed 
Separated 
Never Married

US Citizen	Yes No

Do you receive:
Social Security Disability Benefits?	Yes No
List Amount:________

Other Income?	Yes No	
How Often: _____________
List Amount: _______________

Medicare?	Yes No

Extra help from Social Security?	Yes No

Other pharmacy coverage or Medicare Part D Coverage	Yes No
If Yes, please send a copy of your card, or
Name of Plan:
ID NUMBER________________ EFFECTIVE DATE__________


2. Income Documentation (or proof) must be provided with this application.
Please return the original application with photocopies of supporting documents. 
Social Security, Social Security Disability benefit, Veterans Benefit, pension, 
earnings, interest on saving and/or investments, cash given to you or any other 
income must be reported. Married couples fill out separate form. Mail both 
applications and all documentation in the same envelope.

Rights and Responsibilities
I have read or have read to me all of the statements on this form and the 
information I give is true and complete to the best of my knowledge. I 
understand that I could be penalized if I knowingly give false information. 
I understand that all information I give is confidential and federal and state 
laws limit disclosure of information about me.
I understand and agree to give proof of my statements. I understand that the 
Department of Health and Social Services may contact other persons or 
organizations to obtain the necessary proof of my eligibility.
I certify, under penalty of perjury, that I am a U.S. citizen or Alien in lawful 
immigration status. I must give proof of lawful immigration status and it will 
be checked with the U.S. Citizenship and Immigration Services.

_____________________________________________________ _______________________
Signature of Applicant or Representative                       Date

If representative, please print name, relationship and phone number.

Name_________________________________ Relationship:_______________ 
phone:_______________