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 medicalservices@ECCOcharleston.org.

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*

    Gender*

    Race*

    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)*