FACTMS Patient Assistance Fund Application
Clinic Name:
Contact:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Describe expenses related to TMS therapy that your patient(s) needs:
I agree to only support patients whose income level is less than or equal to 150% of the Federal Poverty Lines.
I agree to provide a report on how funds were used within three months of receiving funds
I agree to provide a testimonial regarding how these funds have benefited my patient(s)
Name of Clinic Representative:
First Name
Last Name
Signature of Clinic Representative:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: