Resolve Initial Intake

1

How much do you owe in medical bills?* This field is required.This is the total amount of your medical bills minus any discounts you've already received and payments already made

Less than $5k

$5,000 - $15,000

$15,000 - $50,000

$50,00 - $250,000

More than $250,000

2

Intake Method

3

What best describes your situation?

I have current medical bill(s) that I need reduced

I have future care and medical bills that I will need help managing and reducing

Both

4

How much do you still owe on your largest bill?An estimate is okay! If you have multiple bills, you can enter that information later.

5

Which hospital or medical provider sent your largest bill?We have relationships with many billing departments to make negotiations move faster.

If you don't know, just click "Continue"

6

Do you have health insurance?* This field is required.It's okay if you don't - we can still help you save. Knowing if you do helps us evaluate your options.

Yes

No

I'm not sure

7

Are any of your medical bills in collections?* This field is required.Don't worry if they are - we can still help.

Yes

No

I'm not sure

8

How are you feeling about your medical bills?* This field is required.Select all that apply

I need an expert

This is wrong and unfair

I feel overwhelmed

I’m researching options

Other

9

Are there any lawsuits, wage garnishments, liens, or pending court dates for your medical bills?* This field is required.

Yes

No

10

Please share the story behind your medical bills.Everyone's situation is unique and the details matter. Our experts will use these to find ways to lower your bill(s). You can always provide more details later. Don't feel like sharing? Simply click "Next."

11

Please tell us a little more about yourself* This field is required.

First Name

Last Name

12

What's your preferred phone number?This is optional but allows us to contact you to discuss how we can help in more detail.

Please enter a valid phone number.

13

What's your email?* This field is required.This allows us to schedule a FREE consult to dive more into how we can help. We won't share you email or contact information with anyone else.

example@example.com

14

15

How much stress are you feeling from these bills?* This field is required.Where 1 is "very little stress" and 5 is "overwhelmed"

1

2

3

4

5

16

We're curious--how did you hear about Resolve?This helps us to reach more people who have issues with medical bills

Friends and family

Web search

Social media

Publication

Billboard, mailer, print ad

Other

17

What makes you most nervous about not resolving your medical bills?* This field is required.Select up to 3.

Falling behind on my bills

Hurting my credit score

Threat of bankruptcy

Continued overwhelming stress

Skipping future medical treatment

Legal action taken against me

Other

18

What has been most frustrating about your medical bills?* This field is required.Select up to 3.

I owe more than I can afford

Overcharges or billing errors

Dealing with billing departments / collections

Time/Effort spent fixing

Price is unfair

I don't know where to begin

Other

19

How many people are in your household?* This field is required.This helps us to identify additional discounts from your medical provider that may be available

20

Is your annual household (pre-tax) income greater than $62,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

21

Is your annual household (pre-tax) income greater than $84,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

22

Is your annual household (pre-tax) income greater than $106,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

23

Is your annual household (pre-tax) income greater than $128,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

24

Is your annual household (pre-tax) income greater than $150,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

25

Is your annual household (pre-tax) income greater than $172,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

26

Is your annual household (pre-tax) income greater than $194,600?This helps us to identify additional discounts from your medical provider that may be available

YESNO

27

You should qualify for Financial Aid!

Based on the income and household size you shared, you should qualify for Financial Aid from the hospital.

We've partnered with DollarFor to provide a FREE service to apply for financial aid on your behalf. DollarFor will use an online form to determine eligibility and then work with you through email and text to secure Financial Aid.

Take Me to DollarFor

If you still want to work with Resolve, click "Next" to continue.

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We're sorry, but we can't help you at this time.

We're currently unable to help you in your specific situation. However, we are constantly growing and improving, and that may change in the future.

Resources for Medical Bills 101

For help tackling your medical bills without an Advocate, explore our guides and resources

Guide to Negotiating Your Medical Bills >

Free Financial Aid >

Borrow from your 401K >

How to crowdfund for medical bills >

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