Medical Financial Assistance Request
The Mental Health Alliance for Athletes offers copay financial assistance to athletes of all ages, providing crucial support for mental health care expenses. Through a simple form submission process, athletes can access financial aid tailored to their needs, ensuring that no individual is hindered from seeking vital mental health support due to financial constraints. By prioritizing the mental well-being of athletes across all age groups, the Alliance champions inclusivity and equitable access to mental health resources within the sporting community, fostering a culture of holistic health and resilience.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
Name & Address of the Provider/Clinic You Are Being Treated By
*
What Type of Financial Assistance Are You Requesting
*
Co-Pay Assistance
Medical / Holistic Treatment Bill
How Much Are you Requesting?
*
Briefly Describe Your Financial Hardship or Reason for Request.
*
Submit
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