Emergency Medication Request Form

Our emergency medication fund helps cover the cost of needed mental health medications for residents of Cleveland County.  The below request should be completed by a mental health provider, community support personnel, your nurse or a doctor's office. 

Limit is $50 per year for each consumer*.  Once request is confirmed a check will be dropped off at the specified pharmacy or mailed depending on pharmacy location.  Prescriptions must be called in or dropped off to pharmacy before a check can be delivered. 

Please note: We do not provide funding for benzodiazepines. 

*Special circumstances where need exceeds $50 will be considered on an individual basis. 

Provider Name *
Provider Name
Agency Phone *
Agency Phone
Consumer First Name and Last Initial *
Consumer First Name and Last Initial
Consumer Date of Birth *
Consumer Date of Birth
$