Indigent Medication Update/Extension Form 1 2026

1. Click ‘Get Form’ to open the Indigent Medication Update/Extension Form 1 in the editor.
2. Begin by entering the date at the top of the form. Clearly print your name, including first, middle initial, and last name.
3. Fill in your STARS ID (if applicable), date of birth, and social security number. Ensure that all personal information is accurate.
4. Provide your address details, including city, state, and zip code. Include a contact telephone number for follow-up.
5. Indicate your marital status and number of people in your household. This information helps assess eligibility.
6. Complete the income and insurance section by answering employment status questions and providing yearly household income details.
7. List any medications you are currently taking along with their prescribed frequency and dosage in the medication section.
8. Finally, review all entries for accuracy before signing at the bottom of the form. Ensure you understand all terms outlined in the agreement.

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