Emergency Medical Request Form — Mental Health Health Association of Cleveland County

Funding for Emergency Medication Request Form

Our emergency medication fund helps cover the cost of needed mental health medications for residents of Cleveland County. The below request should be completed by a mental health provider, community support personnel, your nurse or a doctor's office.

Once the request is confirmed, payment will be called into the pharmacy. For pharmacies that do not accept payment over the phone, a check will be dropped off with the pharmacy or mailed. Prescriptions must be called in or dropped off to pharmacy before a check can be delivered.

Please note: We do not provide funding for benzodiazepines.

Assistance is limited to available funding at the time of request. *Prescriptions must be called in or dropped off to pharmacy before a check can be delivered.

Provider's Name

First Name

Last Name

Agency Name

Agency Phone Number

(###)

###

####

Requesting Provider's Email

Consumer's First Name and Last Initial

First Name

Last Name

Consumer's Date of Birth

YYYY

Pharmacy Name and Address

Medications

Cost of Prescriptions to be Covered