MEDASSIST PROGRAM

How do I apply?

In person application assistance is now available. Please contact us at 408-970-2001 to make an appointment.
Office Location: 777 Turner Dr, Suite 330 San Jose, CA 95128
Office Hours: Monday - Friday 9:00am - 5:00pm

You can apply for the program while funding is available.

OPTION 1: ONLINE APPLICATION

• You will need a valid e-mail address to apply online

APPLY NOW

OPTION 2: PAPER APPLICATION

• Visit the “Forms” page on the left sidebar to download and print out the application form. You can also pick-up a paper copy of the application form at any SCVMC outpatient pharmacy. See below for list of pharmacy locations.

To apply by mail, send to:

Attn: MedAssist
777 Turner Dr, Suite 330
San Jose, CA 95128

To apply by fax, send to:

(408) 885-4093

To apply by email, send to:

[email protected]

Or you can drop-off your completed application at any SCVMC Outpatient Pharmacy during normal operating hours:

VALLEY HEALTH CENTER BASCOM 750 S. Bascom Avenue San Jose, CA 95128 (408) 885-2320	VALLEY HEALTH CENTER GILROY 7475 Camino Arroyo Gilroy, CA 95020 (408) 852-2212	VALLEY HEALTH CENTER MOORPARK 2400 Moorpark Ave San Jose, CA 95128 (408) 885-7675
VALLEY HEALTH CENTER DOWNTOWN 777 E. Santa Clara Street San Jose, CA 95112 (408) 977-4500	VALLEY HEALTH CENTER LENZEN 976 Lenzen Ave, San Jose, CA 95126 (408) 792-5170	VALLEY HEALTH CENTER SUNNYVALE 660 S. Fair Oaks Avenue Sunnyvale, CA 94086 (408) 992-4830
VALLEY HEALTH CENTER EAST VALLEY 1993 McKee Road San Jose, CA 95116 (408) 254-6340	VALLEY HEALTH CENTER MILPITAS 143 North Main Street Milpitas, CA 95035 (408) 957-0919	VALLEY HEALTH CENTER TULLY 500 Tully Road San Jose, CA 95111 (408) 817-1360
VALLEY SPECIALTY CENTER 751 S. Bascom Ave San Jose, CA 95128 (408) 885-2310	O'CONNOR OUTPATIENT PHARMACY 2101 Forest Ave San Jose, CA 95128 (408) 947-2988

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How do I get started?

You will need to gather the following information:

• Patient demographic and contact information
• Prescription information
  • Medication name
  • Copy of prescription OR pharmacy information
• Financial information:
  • Estimate of annual gross household income

  • Estimate of household out-of-pocket healthcare expenses from the previous calendar year. Out of pocket healthcare expenses include:

    • Medical co-payments
    • Prescription co-payments
    • Insurance premiums

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What Documents do I Need?

proof of residence in santa clara county - provide one of the following:

• Current Rental Contract/Lease
• Current Mortgage Statement
• Current Utility Bill (Water, Electric, Gas, Garbage)
• Homeless (Completion of patient statement form)
• Vehicle Registration
• Valid Driver’s license
• Letter of support from person with whom applicant is living and proof of residency for that person

PROOF OF IDENTITY (PHOTO ID REQUIRED) - PROVIDE ONE OF THE FOLLOWING:

• Valid Driver’s license
• Valid Passport
• Valid Government Issued ID
• Valid Work of School ID Card
• Birth Certificate along with valid photo ID

proof of INCOME - PROVIDE ALL THAT APPLY FOR YOUR ENTIRE HOUSEHOLD:

• Recent Tax Return (must include if applicable)
• Check Stubs (at least two(2)
• W-2 Form
• Award Letter (Social Security, Disability, Unemployment, Worker's Compensation)
• Cash Income Statements (including tips)
• Military Benefits Statement
• Rental Income Receipts

proof of VALID PRESCRIPTION - PROVIDE oNE OF THE FOLLOWING FOR EACH QUALIFYING PRESCRIPTION:

• Copy of Hardcopy Prescription
• Pharmacy Contact Information

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What to Expect Next?

Upon receipt of your complete application, MedAssist will determine if you are eligible for a grant based on our program guidelines and subject to available funding. Please understand that all approvals are based on available funding and are on a first-come-first-served basis.   

You can check the status of your application by logging into the portal here or by contacting the MedAssist office.