COVID-19 Immunization Screening and Consent Form
You deserve the get the medical care you need. Medications prescribed by your doctor are an important part of staying well but if you cannot afford them, you run the risk of having your illness worsen.
The Hope Dispensary, a service of Lourdes Hospital, part of Ascension, may be able to help. We are located at 477 State Street in Binghamton, across from Binghamton Plaza.
This program provides help to individuals with no or limited prescription coverage. Patients at or below 400% of the Federal Poverty Level (FPL) will be provided with short-term and long-term assistance. Staff is available to assist with enrollment into the program as well as health insurance through the NYSOH Marketplace and other public programs. Patients can also be assisted with obtaining a primary care physician if needed.
Patients who are eligible for The Hope Dispensary must be at or below 400% of Federal Poverty Guidelines and have no prescription coverage. Patients that have Medicare D but are currently in the coverage gap (Donut Hole) do qualify as not having prescription coverage. Patients that meet the financial guidelines and have prescription coverage but are struggling with copays or deductibles, may be eligible for short-term assistance. If you are unsure if you qualify for the program or would like to know if your medication is available, please call Monday - Friday 9 a.m. to 5 p.m. to speak with one of our staff and to schedule an appointment. Walk-ins are welcome until 3:30 p.m.
Patients are expected to enroll in the program upon their first arrival and annually or if there has been a change in situation.
To enroll, patients must bring:
- Proof of ID
- Proof of Income (for the household)
- Insurance Cards (if applicable)
- Proof of Coverage Gap (if applicable)
*Prescriptions from the provider for each medication requested, is required.
Location: 477 State Street, Binhamton, NY 13901
Phone: (607) 584-9376
Hours: Monday - Friday, 9 a.m. - 5 p.m.
