Facility Requirements
- Federal non-profit tax exempt status
- Must be a qualified facility that provides health care to patients regardless of their ability to pay (i.e. FQHC, FQHC-LA, free clinic, community health center)
- Must be in compliance with State Board of Pharmacy regulations in dispensing medications
- Computerized dispensing capabilities
- Medical Director with current license and DEA number
- Majority of patients with annual household income at or below 250% Federal Poverty Level (FPL)
- Dedicated staff and effective processes and controls in place to perform and document patient eligibility screening according to program requirements
- Ability to retain records: patient application and supporting documentation including patient proof of income and dispensing records for at least 3 years
- Assign a key clinic staff member (involved with medication orders) and a back up staff member for ordering and corresponding with Direct Relief USA
- Ability to maintain medication management policies and procedures specific to program requirement, including: patient screening, dispensing to qualified patients, order request through drug utilization reporting and record retention
- Submit to audit to demonstrate medication dispensing compliance with program requirements
Patient Requirements
- Registered patient of certified clinic
- Uninsured with no public or private assistance for medications
- Income at or below 250% of FPL and adjusted for family size
- Provision of Social Security Number if available
- United States resident (undocumented patients are eligible to receive program drug if they are residing in the US)
- Completion of required application and annual furnishing of income documentation and residency verification (i.e. most recent tax-return, pay-stubs, unemployment statement)
- Willing to sign a consent form for release of patient information for audit purposes
- Patients who are migrant and/or homeless are presumed eligible, an attestation or form verifying eligibility must be completed and kept on file
- Patient has a valid prescription for one of the program medications