Financial Assistance

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Demographics

 
 

Income

 
 
 
 
 
 
 
 
 
 
 
 
 

Assets

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Monthly Expenses

Enter $0 if not applicable.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Documentation Upload

 
Drop your files here
 

Authorization

By typing your name below, you authorize American Pain Consortium to obtain an asset verification. This is deemed necessary to complete the Financial Hardship Application. This also is your certification that the information submitted is correct and authorize you to obtain relevant credit information.

 
 
 
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