Pharmaceutical Services for Adults with Cystic Fibrosis
- 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 $47,907/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
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