Your contribution will help cover the costs of pharmaceuticals, dental care, optical care and hospital procedures for your neighbors without health insurance whose household incomes are at 200% of the federal poverty level or below.

Please indicate the amount of your tax-deductable donation by checking the box that corresponds to your gift:

$25
$50
$75
$100
$250
$500
 
Other :
 


                                          Adopt-A-Patient Program:

By adopting a patient, you can direct your donation
to help those in need in the following areas:

                                          Adopt-A-Patient Pharmacy, $150/year ($12.50 per month)
                                          Adopt-A-Patient Clinic, $300/year ($25.00 per month)
                                          Adopt-A-Patient Special Needs, $500/year ($41.67 per month)
 


Please fill in your contact information here:

      Mr.
      Mrs.
      Ms.
      Dr.

      *First Name:

      *Last Name:    M/I :

      Email:

      Phone Number:

      Name of Organization:

      Title:

 


Address:

*Street:   Apt.#:

*City:   *State:  * Zip:

* Required Fields

Questions and Comments:

Please send the quarterly MCAC newsletter, "Healthcare Connections"
to the above address.

 

Hit the 'Submit' button below to send your information. We will mail you a letter and an envelope within one week of your donation's posting. Thank you for your generosity.