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Forms and Applications

Need immediate prescription coverage?

The Bridge Program may be able to assist you while you are applying for CAREAssist.


CAREAssist Application and Instructions

The CAREAssist program is designed for HIV positive individuals who need financial help to pay for their HIV medications. CAREAssist can pay for medications and medical services for those who qualify.

Once you have downloaded the application, please take a minute to review the instructions. Most of the questions are easy to understand, but some may need an explanation. You may also have to gather information from your personal records.

If you need assistance with any part of the application, please call 971-673-0144 or 1-800-805-2313. 


CAREAssist Eligibility Review

A Client Eligibilty Review (CER) must be completed every six months. Failure to complete and return the CER could delay or end your eligibility with the CAREAssist program.

Cost Share Adjustment Request

If you are a CAREAssist member and your income changes by 25% or more, you may be eligible to apply for a cost share adjustment. Please complete the form and submit to the CAREAssist Program.


CAREAssist Complaints and Grievances

It is the policy of the CAREAssist program to consistently respond with diligence to concerns voiced by clients about the administration of the CAREAssist program or policy issues regarding the program.


WellPartner Mail Order Enrollment

By using the mail order pharmacy, all of your medications (both HIV and non-HIV medications) will be mailed to your home or other location that you choose. If you use the mail-order pharmacy, you will still be able to use a local pharmacy to get urgently needed medication (like a short-term antibiotic). 
  
You can register for the mail order pharmacy by calling Wellpartner at 1-888-206-1605 or filling out a form:

  1. WellPartner Order Form (English)
  2. WellPartner Order Form (En Español)

Once you have gotten your first prescription, you can register for an online account and request refills online.

Medication Therapy Management

In partnership with Ramsell, CAREAssist is pleased to offer Medication Therapy Management (MTM) to eligible clients who are having difficulty adhering to medication regimens. MTM provides phone-based support to patients through direct adherence counseling with an HIV pharmacist. Both medical providers and Ryan White case managers can refer clients of concern to the MTM program.

For medical providers, use the MTM clinical providers referral form 

For Ryan White case managers, use the MTM case managers referral form

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