Pharmacy Eligibility Assessment


To qualify for either the Tulsa County Pharmacy or the Dispensary of Hope Programs, please fill out the form below and a caseworker will determine your eligibility.

If your pre-screening application is approved, you will need to visit the Tulsa County Social Services Pharmacy to pick up your Pharmacy Card. Please bring the card with you each time to present to the pharmacy staff.

Questions or need help filling out this form, call us at 918-596-5560.

Eligibility Questions: Please answer honestly. We will make every effort to help you obtain assistance through the Dispensary of Hope (DOH), Tulsa County Pharmacy program or other means of assistance.

Tell us, in your own words, why you need help and what you are in need of. (Example: I lost my job and I am having trouble making ends meet. I need help with prescriptions, over the counter medications, and/or food.)

Please upload any applicable proof of income documents or screenshots such as tax returns, paycheck stubs, IRS form W2, Food stamp eligibility letter, letter from employer showing compensation, or letter of support.) You can also bring these documents in person to Social Services and we can upload them for you.