MEDASSIST PROGRAM

How do I apply?

Option 1: Online Application

  • Click here to launch the application portal and follow the instructions to complete the application
  • You will need a valid e-mail address to apply online

Option 2: Paper Application

  • Visit the “Forms” page on the left sidebar to download and print out the application form. You can also pick-up a paper copy of the application form at any SCVMC outpatient pharmacy. See below for list of pharmacy locations.

To apply by mail, send to:

Attn: MedAssist
777 Turner Dr, Suite 330
San Jose, CA 95128

To apply by fax, send to:

(408) 885-4093

Or you can drop-off at any completed application at any SCVMC Outpatient Pharmacy during normal operating hours:

VALLEY HEALTH CENTER BASCOM
750 S. Bascom Avenue
San Jose, CA 95128
(408) 885-2320

VALLEY HEALTH CENTER GILROY
7475 Camino Arroyo
Gilroy, CA 95020
(408) 852-2212

VALLEY HEALTH CENTER MOORPARK
2400 Moorpark Ave
San Jose, CA 95128
(408) 885-7675

VALLEY HEALTH CENTER DOWNTOWN
777 E. Santa Clara Street
San Jose, CA 95112
(408) 977-4500

VALLEY HEALTH CENTER LENZEN
976 Lenzen Ave,
San Jose, CA 95126
(408) 792-5170

VALLEY HEALTH CENTER SUNNYVALE
660 S. Fair Oaks Avenue
Sunnyvale, CA 94086
(408) 992-4830

VALLEY HEALTH CENTER EAST VALLEY
1993 McKee Road
San Jose, CA 95116
(408) 254-6340

VALLEY HEALTH CENTER MILPITAS
143 North Main Street
Milpitas, CA 95035
(408) 957-0919

VALLEY HEALTH CENTER TULLY
500 Tully Road
San Jose, CA 95111
(408) 817-1360

VALLEY SPECIALTY CENTER
751 S. Bascom Ave
San Jose, CA 95128
(408) 885-2310

O'CONNOR OUTPATIENT PHARMACY
2101 Forest Ave
San Jose, CA 95128
(408) 947-2988

 



How do I get started?

You will need to gather the following information:

  • Patient demographic and contact information
  • Prescription information
    • Medication name
    • Copy of prescription OR pharmacy information
  • Financial information:
    • Estimate of annual gross household income
    • Estimate of household out-of-pocket healthcare expenses from the previous calendar year (January 2020 – December 2020). Out of pocket healthcare expenses include:

      • Medical co-payments
      • Prescription co-payments
      • Insurance premiumns


What Documents do I Need?

Proof of Residence in Santa Clara County – Provide ONE of the following:

  • Current Rental Contract/Lease
  • Current Mortgage Statement
  • Current Utility Bill (Water, Electric, Gas, Garbage)
  • Homeless (Completion of patient statement form)
  • Vehicle Registration
  • Valid Driver’s license
  • Letter of support from person with whom applicant is living and proof of residency for that person

Proof of Identity (Photo ID Required) – Provide ONE of the following:

  • Valid Driver’s license
  • Valid Passport
  • Valid Government Issued ID
  • Valid Work of School ID Card
  • Birth Certificate along with valid photo ID

Proof of Income – Provide ALL that apply for your entire household:

  • Current Check Stubs (all stubs not older than 45 days from application date)
  • Tax Return (current tax year)
  • Award Letter (Social Security, Disability, Unemployment, Worker’s Compensation)
  • Cash Income Statements (including tips)
  • Military Benefits Statement
  • Rental Income Receipts

Proof of Valid Prescription – Provide ONE of the following for each qualifying prescription:

  • Copy of Hardcopy Prescription
  • Pharmacy Contact Information


What to Expect Next?

Upon receipt of your complete application, MedAssist will determine if you are eligible for a grant based on our program guidelines and subject to available funding. Please understand that all approvals are based on available funding and are on a first-come-first-served basis.   

You can check the status of your application by logging into the portal here or by contacting the MedAssist office.

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