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North Dakota Insurance Department
Jon Godfread, Commissioner
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A person may be eligible for assistance through the Prescription Connection program if he or she meets the following requirements:
• You must be a North Dakota resident.
• You do not qualify for any state assistance programs for prescription drugs.
• You have low income and/or you have financial challenges affording your prescriptions.

Additionally, each individual pharmaceutical company has its own eligibility criteria.

Prescription Connection Application SFN 58370

To email this document to the Prescription Connection program, complete the following steps:
  1. Fill out the form.
  2. Choose File>Save As (or click the save icon) and save it to your computer.
  3. Open your email account and create a new message.
  4. Attach the file to the email message and send it to ndshic@nd.gov.

North Dakota Insurance Department
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
Phone 701.328.2440
Toll free 800.247.0560
Fax 701.328.4880

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