Assistance Application

Personal Information

First name(Required)

Last name(Required)

Date of birth(Required)

Address(Required)

Address line 2

City(Required)

State(Required)

ZIP(Required)

Primary phone(Required)

Alternate phone

Email address(Required)

If the patient is under 18 years old, please provide the name of his/her parent or guardian:

Parent/guardian name

Demographic Info

Patient race(Required)

Caucasian

Black/African American

Asian

Native American

Hispanic

Other

Do not wish to answer

Patient sex(Required)

Male

Female

Patient employment(Required)

Employed

Unemployed

Disabled

Retired

Student

Diagnosis Information

Diagnosis(Required)

Other Diagnosis

Date of diagnosis(Required)

Physician name(Required)

Hospital / clinic(Required)

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Phone(Required)

Office contact name(Required)

Office contact phone(Required)

Assistance Details

Co-pay amount:(Required)

Nutritional supplements (please list)(Required)

Notes:

Please provide three hotels/motels closest to your treatment facility center in order for staff to option the best nightly rate.

Name of hotel(Required)

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Phone(Required)

Name of hotel

Address

City

State

ZIP

Phone

Name of hotel

Address

City

State

ZIP

Phone

Note: reservations will be guaranteed for one night only. Additional nights will be provided as approved by the Financial Assistance Committee if the patient complies with hotel policies. It is the responsibility of the patient to keep any reservation that is made on their behalf. Failure to do so may result in all future reservations being forfeited indefinitely. If a cancellation is needed, this office must be notified one business day prior to check-in.

Notes:

Financial Background

We are required to ask for applicants’ financial information before providing support. Your information is stored securely, and will not be shared or sold.

Household annual income(Required)

Documents

Please scan or photograph the following documents and upload via this form. Preferred formats: JPG, PDF.

Most recent tax return (first and second page only)

Max. file size: 256 MB.

(1040, 1040A, 1040EZ)

I do not file a tax return

Wage or social security/disability statements(Required)

Max. file size: 256 MB.

Type full name to sign(Required)

Personal Information

Demographic Info

Diagnosis Information

Categories

Assistance Details

Financial Background

Documents