Madison Clinic
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Madison Clinic Financial Counseling

Pharmacy Co-Pay Exemption Form

Harborview Medical Center strives to provide financial assistance to our patients in need. In order for us to consider your prescription under financial assistance, you will need to be assessed by the staff at Financial Counseling.

Please take this Co-pay exemption form to Room GEC-49 to begin that process. They will provide you with information, ask you some questions, and assess your situation. This process includes providing financial documentation that will determine what level of assistance, if any, you qualify for. At the completion of your visit with Financial Counseling, bring this completed form back to the Pharmacy to obtain your medications.

DIRECTIONS:

Madison Clinic Pharmacy To Financial Counseling:

From 2WC take the elevator to the ground floor to the main lobby. From the main lobby turn right toward the Outpatient Pharmacy and Gift shop. Continue following the hallway past the Outpatient Pharmacy until you reach a 4 way intersection. Turn right and walk about half-way down the hall. The Financial Counseling window is located at room GEC-49 on your right.

Financial Counseling to Madison Clinic Pharmacy:

Walk down the hallway to the 4 way intersection and turn left into the main hallway. Continue walking until you reach the main lobby. Turn left and take the elevators to 2WC/Madison Clinic.

Coverage Options

Department of Social & Human Services - To apply for services click on the link below or contact your Madison Clinic case manager.

Washington State Department of Health - HIV Early Intervention Program (EIP). Contains a comprehensive list of the medications covered by this program.