Medication Bridge Program Application

Individuals who are not yet members of CAREAssist and need emergency coverage for prescription medications related to their HIV care may be eligible for up to a 90 day supply, which includes medical visits and lab work necessary to determine appropriate HIV treatment regimines. This form must be completed by your physician.

Coverage is available to Primary Care Providers establishing a clients ongoing medical needs.  Payments for speciality care referrals are not available at this time, although exceptions will be considered with prior authorization.

• Program Summary and Instructions

CAREAssist Application and Instructions

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 (from Portland) or 1-800-805-2313 (from outside Portland).

• Affidavit of Zero Income Form - you must complete this form and submit it with your application if you are reporting zero income.
• HIV Verification Form - you must ask your health care provider to sign this document and submit with your application.

NEW! -Solicitud confidencial de CAREAssist & Instrucciones

• Declaración de no ingresos
• Formulario de confirmación VIH/Sida

CAREAssist Eligibility Review Instructions and Form

Cost Share Adjustment Request

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

NEW! - Pedido de ajuste en la coparticipacion