Medical Expense Support Request Form
Please fill out this form to request support for medical expenses.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Doctor’s Name
*
Hospital/Clinic Phone Number
*
Please enter a valid phone number.
City of Residence
Explain the type of medical assistance you need
Upload recent Prescription
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Are you currently employed?
Yes
No
Do you have health insurance?
Yes
No
What is your household’s gross annual income?
Less than $20,000
$20,000-$49,999
$40,000-$59,999
$60,000-$99,999
$100,000 or more
Proof of income
Browse Files
Drag and drop files here
Choose a file
You can upload recent pay stub, tax returns, government assistance letters, or any document showing your household’s income.
Cancel
of
Proof insurance will not cover cost
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I confirm that the information I provided is accurate to the best of my knowledge. I give Medicine for Mercy permission to verify the details provided with my healthcare provider or pharmacy if needed.
*
Date
*
-
Month
-
Day
Year
Date
Is there anything you’d like us to know?
Continue
Continue
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