Once you have checked your eligibility, please complete this application. Be sure to follow all of the instructions and call if there are any questions.
To be eligible for the program:
- Fully complete the application. Do not leave any blanks
- Attach the proof of income
- Attach the proof of residency
- Sign the Notice of Privacy Practices (NOPP)
If one of those is not complete, it will take longer before you can be approved for the Wyoming Medication Donation Program
***Note: It is NOT possible to complete the application online and email from this website. Printing the application, and scanning it to email is possible, however the network may not be secure and this is not the preferred method. Faxing the application, and calling to be sure we received it, it the best method.***
The Dispensing Sites listed below work with the WMDP to provide patients in those towns with local aid. Please contact the Dispensing Site closest to you to see how you can apply through them. If there is not a site near you, please contact us and we can mail the medications directly to your door.
- Health Care for the Homeless: (Ph) 307-235-6116
- Health Works Pharmacy: (Ph) 307-637-7000
- Cedar Mountain Center (West Park Hospital): (Ph) 307-578-2529
- Downtown Clinic: (Ph) 307-745-8445
- Sheridan Health Center: (Ph) 307-674-6995