Financial Assistance Application

Patient/Responsible Party

First Name*

Last Name*

Birth Date*

E-mail Address (if available)

Phone Number

Spouse's Full Name

Spouse's Birth Date

Household Information

How Many Members Are in Your Household?*

Include yourself and spouse (if applicable) in calculation

Select or enter value

Dependent 1 Name

Dependent 1 Birth Date

Dependent 1 Relationship to Patient

Dependent 2 Name

Dependent 2 Birth Date

Dependent 2 Relationship to Patient

Dependent 3 Name

Dependent 3 Birth Date

Dependent 3 Relationship to Patient

Dependent 4 Name

Dependent 4 Birth Date

Dependent 4 Relationship to Patient

Dependent 5 Name

Dependent 5 Birth Date

Dependent 5 Relationship to Patient

Dependent 6 Name

Dependent 6 Birth Date

Dependent 6 Relationship to Patient

Dependent 7 Name

Dependent 7 Birth Date

Dependent 7 Relationship to Patient

Dependent 8 Name

Dependent 8 Birth Date

Dependent 8 Relationship to Patient

Dependent 9 Name

Dependent 9 Birth Date

Dependent 9 Relationship to Patient

Dependent 10 Name

Dependent 10 Birth Date

Dependent 10 Relationship to Patient

Annual Household Income

Total Annual Income from Wages*

Income from wages per year.

Pension, Retirement, Social Security Income

Unemployment, Disability Income, Etc.

Child Support,Alimony

Total Assets

Cash

Checking Account Balance (if applicable)

Savings Account Balance (if applicable)

Stocks or Bonds Balance (Iif applicable)

Do You Receive the Following Forms of Assistance?

SNAP (Food Stamps)

Housing Assistance

If you receive one of the above forms of assistance, please attach copy of approval letter to "attachments" section below.

Attachments - Please Attach the Following as Proof of Income

- Most Recent Tax Return - Must be a full tax return from within the last two (2) years - Copy of the most recent pay stub with Year-to-Date total pay If you cannot provide a copy of your most recent tax return, please supply one of the following as proof of income - Last two (2) months of Bank/Account Statements from Assets - Approval Letter for L.E.A.P (Energy Assistance) - Social Security Benefits If you don't have this information readily available, you can still complete the application to see if you qualify. You will be asked to supply this information before final approval.

Drag and drop files here or

Additional Information

Please explain any additional circumstances that may be pertinent to the approval of your application for assistance (i.e. recent life changes, employment changes, etc.).

Thank You For Applying!

You will be contacted in the next 30 days about the status of your application

Send me a copy of my responses

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