Required for Complete Application

After your Financial Assistance Request is screened and you meet initial eligibility, our Patient Resource Coordinator will contact you to make sure all additional documentation is submitted.  You may go ahead and submit these documents with your initial Financial Assistance Request.  These documents are needed to complete a full application.

• • Last 2 pay stubs or proof of unemployment (If your income is solely Social Security or Social Security Disability Income, then a copy of Social Security or Social Security Disability Income statement or letter).
  • Most recent federal tax return (first 2 pages) or Schedule C if self-employee
  • Copy of utility bill
  • Your Story
  • Medical/Health Information Release & Authorization
  • Publicity Release
  • Copy of driver’s license or alternate ID
  • If you are insured:  Copy of current medical card (front and back)
  • If you are uninsured: Copy of Medicaid and/or Social Security Disability rejection letters, if applicable