Financial Assistance Program

Financial Assistance Program
Our practice is committed to care for all patients regardless of their ability to pay. Patients who are unable to pay for services may be eligible for financial assistance. Please complete and return the following form with the requested documents to be evaluated for financial assistance.
Patient Information
Patient Name

First NameLast Name
Date of Application
Date of Birth
Social Security Number
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Income
Household Size: Number of family members (including you) who live in your home
Household Income (Annual): Annual gross income for all family members in the household
Check ALL income types that apply

Employment Income/ WagesBusiness Income/ Rental PropertyUnemployment Benefits/ DisabilityAlimony/ Child SupportPension/Retirement/ Annuities Social Security/Veterans Benefits
Proof of Income
To qualify for financial assistance, we must verify your income. Please provide one of the following within 30 days of submitting this application.

1. Most recent year federal tax returns for all persons who live in your home
2. Most recent 2 pay stubs for all persons who live in your home
3. Most recent year W-2 forms for all persons who live in your home
4. Social Security Benefit Letter
5. Most recent 2 bank statements for all persons who live in your home

I hereby declare that all information set forth above in this application is true, accurate, and complete in all respects. I also acknowledge and agree that IF PROOF OF INCOME IS NOT PROVIDED WITHIN 30 DAYS OR IF I DO NOT QUALIFY FOR FINANCIAL ASSISTANCE, I WILL BE BILLED IN FULL FOR ALL SERVICES PROVIDED.
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Financial Assistance Program

Patient Information

Household Income

Proof of Income