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CommunityRx Kansas Enrollment Form

To enroll in this program you must:

1. Be a resident of Kansas and have annual income levels at or below those indicated in the following table:

Family Size	Annual Income	Family Size	Annual Income
1	$31,200	5	$74,400
2	$42,000	6	$85,200
3	$52,800	7	$96,000
4	$63,600	8	$106,800

For family units greater than 8, add $10,800 to the annual income figure for each person above 8.

2. You cannot qualify for VA benefits, Medicaid or Medicare, or any other funded prescription assistance.

3. Review the list of covered medications to be sure the coverage meets your prescription needs. Complete the enrollment form.

4. Return the enrollment form to Prescription Network of Kansas.

At this time enrollment for the first year of coverage is FREE.

Head of Household Information

Please Print Clearly

Last Name:

You must meet income guidelines based on the table above.

First Name:

Sex (M/F):

Birthdate (mm/dd/yyyy):

Mailing Address:

DO NOT SEND ANY

Apt or Suite:

PRESCRIPTIONS WITH THIS

City:

APPLICATION

State:

Zip:

County:

RETURN ENROLLMENT FORM TO:

Daytime Telephone:

Prescription Network of Kansas

Annual Income:

1020 SW Fairlawn Rd

Group #:

PNK/1740

Topeka, KS 66604

Dependent Information

DEPENDENT #1 Spouse Child		DEPENDENT #2 Spouse Child
Last Name:		Last Name:
First Name:		First Name:
Middle Initial:	Sex: Male Female	Middle Initial:	Sex: Male Female
Birthdate (mm/dd/yyyy):		Birthdate (mm/dd/yyyy):
If you have more than two dependents, attach another piece of paper with the above information provided on each dependent to be covered.

Income Confirmation and Release of Liability

I certify that I have read and understand services offered by CommunityRx Kansas and my responsibilities as a participant as described on this application, and agree to the terms contained in this document. I also certify that the information provided in this application is accurate and true to the best of my knowledge and belief. I understand that participation in this program by pharmacies is strictly voluntary and that they receive no payment for their services by Prescription Network of Kansas. I certify that I do not receive any other benefits from Medicaid, Medicare, health insurance, VA health benefits or any other funded prescription assistance and I give consent to Prescription Network and CommunityRx Kansas to obtain the status of any pending Medicaid application. By signing this application I release Prescription Network of Kansas and CommunityRx Kansas, its pharmacies and all service providers, affiliated organizations and any public or private agencies or financial supporters and their agents and assigns from any and all claims of liability in contract or tort arising out of the actions of any provider in performing services related to this program.

____________________________ _______________________________________________________

Date Signature of Cardholder/Head of Household