Application Forms

Pharmaceutical Services for Adults with Cystic Fibrosis

Program Requirements:

  • DIAGNOSIS OF CYSTIC FIBROSIS VERIFIED BY CF DOCTOR.
  • MUST BE A NEW JERSEY RESIDENT.
  • MUST BE 18 YEARS OR OLDER.
  • INDIVIDUAL ANNUAL INCOME LESS THAN $46,876/YEAR.

Complete the application and return it with all required documents to:

New Jersey State Organization Of Cystic Fibrosis
P.O. Box 3648
Wayne, NJ 07474-3648

Phone: 973-595-1232
Fax: 973-595-1718

 

The documents needed to process your application are:

  • Completed “Application” (original)
    • Copy of your New Jersey Driver’s License or other proof of residency.
  • Completed, signed and notarized “Insurance Affidavit”.
  • Copies of all current Health Insurance Cards.
  • Signed and notarized “Income and Acceptance Affidavit”.
    • Copy of your Federal Tax Return with all W2’s, 1099’s and/or your SSI Benefits Statement.
  • Signed “Signature Form” for Shoprite or Wegmans. You can only shop at one or the other.
  • Signed “Patient Authorization for Health Information Disclosure” (HIPPA compliant)

Failure to submit ALL of the above items will delay your acceptance into the Program.

How to get the forms: 

The required applications and forms are in PDF format.
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Required Application Forms
PDF format.