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First Name: *

Last Name: *

Phone: *
Please provide the best contact number in case our team has any questions.

Email:

Documents

Please include all documents that apply to your current situation.

Application: *
Please attach your completed financial assistance application in PDF format.

Paystub 1:
Your most recent paystub, including gross year to date income, from patient and patient’s spouse. If patient is a minor, we will require paystubs from parents or guardians.

Paystub 2:
Your second most recent paystub, including gross year to date income, from patient and patient’s spouse. If patient is a minor, we will require paystubs from parents or guardians.

1040 Tax Return:
Most recent 1040 Federal Income Tax Return including all schedules (or explanation letter). If a 1040 Federal Income Tax Return has not been filed, please write a letter explaining why not.

Social Security Award Letter:
Current Social Security Awards Letter showing gross monthly benefit amounts. To request a new award letter, please call (800) 772-1213.

Pension 1099:
Pension 1099 or letter from payer documenting gross monthly award amount.

Alimony:
Alimony documents paid or received.

Child Support:
Child support documents showing paid or received.

VA Benefits:
VA benefits award letter.

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