TIIBA'S Eagle Foundation Copay/Deductible Assistance Application
Please complete this entire form.
Name (parent/legal guardian)
Name of Client receiving services
Street Address Line 2
State / Province
Postal / Zip Code
Who referred you? (Agency/Person)
Annual Income for Household/Source of Income
Agency that you will receive therapy (Speech, OT, ABA) and how often are you receiving these services.
Agency must provide documentation of services needed
How much is your copay/deductible?
How much assistance are you requesting?
Please provide any additional information of any kind that will help us to better understand your situation please do so below.
Please attach your last 4 check stubs OR last year's tax return OR an award letter for any government assistance along with documentation of services needed on letterhead from the provider.
Should be Empty:
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