Patients Supporting Patients Application for Financial Support

Thank you for your interest in receiving financial assistance with your Direct Primary Care healthcare. Please complete this form to apply for financial support for a Cape Cod-based Direct Primary Care practice. Applications will be reviewed by the Board of Directors of Patients Supporting Patients on a periodic basis. Filling out this application is not a guarantee of financial support.The Board will notify you if you have been awarded a full or partial scholarship for Direct Primary Care services.

Date

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Age Range

Do you have a current primary care provider?

Which Cape Cod direct primary care practice would you like to join or are currently enrolled in?

Who is your current primary care provider?

How much out of pocket could you afford to pay toward a Direct Primary Care membership each month?

How long are you applying for financial assistance for ?

Please tell us a little bit about yourself to help support your application?

Patients Supporting Patients, Inc.