Application for Financial Assistance

Preferred Healthcare acknowledges the importance of providing financial assistance to patients who demonstrate a genuine need for support in meeting their medical expenses.

This application is for determining eligibility for financial assistance to help pay for outstanding medical bills and patient co-payments owed to Preferred Healthcare and/or its subsidiaries. If your financial situation changes, please file another form.

The following documentation is required for consideration:

1) Proof of patient's income reported on this form or other financial hardship, or SSI or other government financial assistance (WIC, EBT, etc)
2) Driver’s license or state identification

Final approval for any financial assistance will be determined at the discretion of the Preferred Healthcare's practice management.
Patient applying for assistance *

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*

Area CodePhone Number
Email*
example@example.com
Annual Income or Wages*
Household Size*
Total Annual Expenses*
Provide a brief summary of your situation and why assistance is needed*
Upload Required Documents*

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