STUDENT ATHLETE FINANCIAL ASSISTANCE REQUEST

STUDENT ATHLETE FINANCIAL ASSISTANCE REQUEST
Program Statement

TRA Medical Imaging (TRA) and the Tacoma-Pierce Athletic Commission (TAC) have partnered to launch a special community program that provides free or reduced‑cost diagnostic imaging services to local student‑athletes who demonstrate financial need. We believe that fear of paying for an injury should never be a barrier to participating in youth athletics in our community. This collaboration is designed to ensure that student athletes receive timely, medically necessary imaging to support their health, injury evaluation, recovery, and safe return to play.
PATIENT INFORMATION
Patient Name:
Date of Birth:
Email:
Phone Number:
Address:
PARENT INFORMATION
Parent Name:
Email:
Phone Number:
Address:
NOTE: A valid imaging order must be provided before scheduling.
REQUESTED IMAGING EXAM
Please indicate the exam(s) for which you are seeking financial assistance:

X-rayUltrasoundMRICTOther
Reason for the exam/ clinical indication:
FINANCIAL ASSISTANCE REQUEST

TRA’s Student Athlete Financial Assistance Program provides imaging at reduced or no cost for approved applicants. No cash awards are issued. This program is intended for patients who otherwise face a financial barrier to receiving medically necessary imaging.
Date:
Should be Empty: