Prescription Assistance Form

Our Prescription Assistance Program helps our patients fill monthly prescription refills at a reduced or no cost at all. To apply for our program, please complete the form below. For more information, please call (843) 416-7130 or email

Please make sure to fill out all the required fields for this application to be submitted successfully.

Once the form is submitted, an ECCO staff member will follow up within 2 business days using the contact information you provide below.

    Are you a current ECCO client?

    Have you ever visited ECCO before?

    Personal Information

    Date of Birth*



    Marital Status*

    Contact Information

    Do you live in the city of Charleston?*

    How many adults are in your household?*

    How many minors are in your household?*

    Employment Information

    Employment Status*

    Date of last employment*

    Household Earnings (Income, Social Security, Pension, Disability, etc)

    To receive assistance, eligible clients are required to provide the following items. If you have them available, please attach here:

    • Paystubs documenting last 30 days of income.

    • Unemployment Benefit Letter

    • Letter from an employer stating last day of work or a reduction of hours worked.

    • If impacted by COVID-19, a letter stating how it has impacted them financially

    Other Info

    How did you hear about ECCO?*

    Applicant Acknowledgement of Agency Obligation to Prevent Duplication of Charleston County Federally Funded CDBG CARES 20 Financial Assistance*

    Release of Information (ROI)*