II. Application: Any contract provider may request to use BMHS Pharmacy Funds for an indigent patient who is a Baltimore City resident. Priority for accessing these funds shall be given to individuals who meet one or more of the following criteria:

* Has applied for, but not yet received, Medical Assistance or Pharmacy Assistance.

* Is homeless

* Has a diagnosis of serious and persistent mental illness, or serious emotional disturbance

* Is leaving a hospital or institution

III. Definitions:

1. Medication refers to psychotropic medications prescribed by a BMHS mental health provider.

2. Providers are individuals, agencies or facilities that have a valid contract with BMHS to provide mental health services to residents of Baltimore City.

3. Request for Financial Assistance to Purchase Medication Form: This form must be used by providers when submitting request for assistance with purchasing medications (see download area below).

4. Invoice is the pharmacy bill for the prescribed medication for which financial assistance is being requested.

IV. Procedure: The completed form (2 pages) is to be submitted to BMHS when requesting BMHS pharmacy funds.

1. Providers submit Request Form and invoice to BMHS.

2. When a request is received, it shall be stamped with date received and given to a Clinical Program Director

3. The Clinical Program Director shall review and respond to the requesting provider within 2 work days of receipt.