No Income Attestment Form is an internal form used by Prescription Assistance to submit on your behalf attesting by written signature that you have no form of income documentation to submit. We ask that you print this form. Sign and date it and include it with your application to our program.
If you would like more information or help with the application process, please call toll free 1-800-472-0031.
Mission Statement
If you cannot provide income documentation....
Community Health Services Inc. is where North Dakotans can find, compare, choose, and get complete health coverage that best fits their needs and budget.
Call Community Health toll free at 1-800-842-8693 or stop by in person
810 4th Avenue S. Suite 101
Moorhead, MN 56560
Form 4506-T is an Internal Revenue Service (IRS) document that is used to retrieve past tax returns, W-2, and 1099 transcripts that are on file with the IRS. The document gives permission for a third party to retrieve the tax payer’s data. The taxpayer must sign and date the 4506-T to retrieve the income data.
Contact Information
If you live in Minnesota....
The Community Resource page provides individuals within our community an opportunity to seek local services from the comfort of home. The following information is provided to help each individual applying to the Prescription Assistance Program find the proper documents needed to complete an application for prescription medication. We have also listed a few non-profits within our community that may be able to assist with various instances of need.
To promote healthier living through advocacy, comprehensive resources and managed care by helping individuals in need obtain prescription medication.
If you claim social security and receive Medicare....
Application Materials
Medicaid is a program designed to assist individuals and families who do not have health insurance, or who have health insurance that does not cover all of the individual's or family's medical needs. Medicaid eligibility is based on income, and in some cases, assets. It provides comprehensive health coverage, as well as assistance with Medicare premiums, coinsurance and deductibles. Coverage may begin up to three months prior to the month of application. Medicaid benefits are extended to the elderly, blind or disabled individuals, pregnant women, children to the age of 21 years, and parents of eligible children.
Community Resources
MNsure marketplace is where Minnesotans can find, compare, choose, and get complete health coverage that best fits their needs and budget. MNsure is the one place to find out if you qualify for a low-cost or free plan.
Whether you currently buy health insurance on your own, or you are uninsured, you can use MNsure.
If you live in North Dakota....
Extra Help/Low - Income Subsidy is for Medicare beneficiaries who qualify with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $4,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.
Affordable Care Coverage
If you cannot provide income documentation....