Apply for Financial Assistance

Instructions

  1. Download the financial assistance application to your computer.
  2. Open the application, fill out, and save. Note: you must use Adobe Reader to fill out.
  3. Fill out the online form below and use the appropriate fields to upload your completed application and supporting documents.

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Please provide the best contact number in case our team has any questions.

Documents

Please include all documents that apply to your current situation.

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Please attach your completed financial assistance application in PDF format. Combined file sizes cannot exceed 15MB

Your most recent paystub, including gross year to date income, from patient and patient’s spouse. If patient is a minor, we will require paystubs from parents or guardians. Combined file sizes cannot exceed 15MB

Your second most recent paystub, including gross year to date income, from patient and patient’s spouse. If patient is a minor, we will require paystubs from parents or guardians. Combined file sizes cannot exceed 15MB

Most recent 1040 Federal Income Tax Return including all schedules (or explanation letter). If a 1040 Federal Income Tax Return has not been filed, please write a letter explaining why not. Combined file sizes cannot exceed 15MB

Current Social Security Awards Letter showing gross monthly benefit amounts. To request a new award letter, please call (800) 772-1213. Combined file sizes cannot exceed 15MB

Pension 1099 or letter from payer documenting gross monthly award amount. Combined file sizes cannot exceed 15MB

Alimony documents paid or received. Combined file sizes cannot exceed 15MB

Child support documents showing paid or received. Combined file sizes cannot exceed 15MB

VA benefits award letter. Combined file sizes cannot exceed 15MB

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