Magnifying Research Medical Expense Assistance Form

Magnifying Research Medical Expense Assistance Form
Please follow these steps carefully:

1. Read each section carefully and enter the information as thoroughly as possible.

2. Fill out the entire application and be sure to sign the required signature boxes.

3. Electronically submit the form (in person forms cannot be accepted). You will receive a confirmation email that Magnifying Research received your submission.

4. A Magnifying Research representative will be in touch with you if further information or documentation is needed. Please allow 2-4 weeks for processing. You will be notified by email/phone once your eligibility is established. If we need further information for contacting your medical provider, we will obtain it at that time.

Eligibility and Payment Policies

- Eligibility for financial assistance through Magnifying Research is based on household income. Single-person households with an annual income below $30,000 and multi-member family households with an annual income below $60,000 may qualify for assistance. Additionally, each eligible household member is limited to a maximum of $1,200 in financial assistance per calendar year.

- Financial assistance is intended to support individuals legally residing in the United States and expenses associated with qualifying medical care or medical expenses incurred in the United States. Applicants may be required to provide reasonable documentation establishing their current legal U.S. residency. Note: Eligibility under this policy is based on legal U.S. residency and is not intended to establish or determine an applicant's citizenship status.

- Magnifying Research will make payments directly to the medical provider, pharmacy, supplier, or other third party responsible for the qualifying expense rather than directly to the applicant.

- Magnifying Research provides financial assistance only for medical expenses that are currently outstanding and unpaid. The Foundation does not reimburse applicants for medical expenses that have already been paid.

- Financial Assistance may be limited by funding sources available to Magnifying Research.

APPLICANT PERSONAL INFORMATION
Name

First NameMiddle NameLast NameSuffix
Date of Birth
mm/dd/yyyy
Type of Legal Identification
Identification Number
Only enter the last 4 digits of the Identification Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
HOUSEHOLD INFORMATION
# of Additional People in Household
Name/Age/Relationship of Other Members of Household

Household Income
Household annual income is the total income earned by everyone in your household before taxes and other deductions. You can use either the Adjusted Gross Income (AGI) reported on last year’s tax return(s), or an estimate of your household’s total income for the current year.
Applicant's Annual Income
Souse/Partner's Annual Income (if appropriate)
Other Member's Annual Income (if appropriate)
Are you or any member of your household currently receiving federal or Colorado state financial assistance in the form of any of the following?
You may select as many options as needed
You do not need to provide proof of income eligibility up front. Magnifying Research reserves the right to ask for financial documentation later if needed to determine eligibility.

Supporting Documentation
In your own words, please explain why you need financial assistance for your medical expenses, and what those medical expenses are.

0/500
Please upload supporting documentation for the expenses for which you are requesting assistance, such as current medical bills, invoices, statements, or other documentation showing the outstanding amount due.

Cancelof
Are you able to pay a portion of this bill ?
If so, how much can you pay?
$xxx

Signature Confirmations
Self-Certification Statement
I understand that Magnifying Research does not provide duplicate financial assistance or assistance that exceeds the amount due for a specific bill or invoice. I certify that I am not attempting to defraud Magnifying Research by requesting financial assistance for the purpose stated in my application. I understand that if Magnifying Research determines that a request or payment involves fraud, misrepresentation, or a violation of its established guidelines, Magnifying Research may take appropriate action in accordance with its organizational policies and procedures. Such action may include voiding or recovering the financial assistance provided and, when appropriate, pursuing legal action.
Signature
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Consent for Release of Medical Financial Information
I authorize Magnifying Research and its authorized representatives to obtain, review, and verify information related to my request for financial assistance, including documentation pertaining to medical bills, prescription bills, medical invoices, and other healthcare-related expenses. I understand that this information may be used solely to determine my eligibility for financial assistance, verify the amount owed, and prevent duplicate or excessive financial assistance. I authorize healthcare providers, pharmacies, billing agencies, insurers, and other relevant entities to release the necessary information to Magnifying Research and its representative for these purposes.

By signing below, I acknowledge that I have read and understand this consent and voluntarily authorize the release and use of the information described above.
Signature
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Legal Residency Affidavit
I understand that Magnifying Research provides financial assistance only to individuals who are legally residing in the United States. I further understand that financial assistance is limited to eligible medical care and medical expenses incurred within the United States.

By signing below, I attest that I am legally residing in the United States. I understand that I may be required to provide documentation verifying my legal residency in order to qualify for and receive financial assistance.
Signature
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Magnifying Research Medical Expense Assistance Form

APPLICANT PERSONAL INFORMATION

HOUSEHOLD INFORMATION

Household Income

Household annual income is the total income earned by everyone in your household before taxes and other deductions. You can use either the Adjusted Gross Income (AGI) reported on last year’s tax return(s), or an estimate of your household’s total income for the current year.

You do not need to provide proof of income eligibility up front. Magnifying Research reserves the right to ask for financial documentation later if needed to determine eligibility.

Supporting Documentation

Signature Confirmations

Self-Certification Statement

Consent for Release of Medical Financial Information

Legal Residency Affidavit