HG Relief Project, Application

Application for Financial Assistance

The Hyperemesis Gravidarum Relief Project
The HG Relief Project is committed to removing financial barriers that patients face in accessing care for nausea and vomiting in pregnancy. Alabama Pregnancy Medicaid is excellent! If you qualify for pregnancy Medicaid, that is your best option to get your care completely covered.

If you do not qualify for Medicaid OR if you have the BCBS High Performance Plan in addition to Medicaid, please fill out this application for financial assistance!

Apply & See Eligibity information for Alabama Pregnancy Medicaid
Are you eligible for Alabama Pregnancy Medicaid?

YesNo
Do you live in Alabama?

YesNoNo, however, I will be in Alabama at The Morning Sickness Clinic for treatment
Patients are elligible to recieve financial assistance from The HG Relief Project, if they live in Alabama or are in Alabama at The Morning Sickness Clinic for treatment. Patient's household income must be less than 300% of the Federal Poverty Limit to qualify for assistance. Patient's who are between 300%-500% of the Federal Poverty Limit will be considered on a case by case basis.

You will be asked to submit last year's tax return as well as a copy of your most recent pay stub for all persons working in the home and providing financial support for the pregnant person, including her own pay stubs. If the father of the unborn baby is living in the household, his income must be included. Additional documents may be required as determined by The HG Relief Fund.

If your income is under 146% of the Federal Poverty Limit, you will be asked to apply for Medicaid.
Please fill out this HELP score (symptom questionaire)
What is your HELP score today?
I. Personal Data

Tell us about yourself
Full Name*

First NameLast Name
Birthdate*

MonthDayYear
Mobile No*
Email *
Where the confirmation will be send to
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload your last year's tax return. (If you have Medicaid, you can upload that here rather than provide tax returns)

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If you have Medicaid and don't have a photo of your card, you can enter your Medicaid # here:
Please upload your the last month's pay stubs for all persons working in the home. If the father of the unborn baby is living in the household, his income must be included. You do not need to upload files here if you've already provided your Medicaid info above.

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If no one in the home is working, please explain your circumstances:
How much money feels doable for you to pay for each appointment in our clinic? How often you need to be seen will depend on your symptom severity, but often our patients come in 1-2x a week until symptoms subside.
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Do you have any difficult financial circumstances that you feel we should know about?
Signature

Clear
Should be Empty:

Application for Financial Assistance

I. Personal Data