Financial Assistance Elibility Form

Financial Assistance Elibility

Our clinic is committed to making care accessible regardless of financial circumstances. Patients who qualify based on household income and family size may be eligible for reduced fees or free services under our financial assistance program. Please complete this form.

Full name

Date of birth

Month

Day

Year

Phone

Household information

Number of people in household (including yourself)

Employment & Income information

Employer Name (if applicable)

Annual Gross Income (before taxes)

Other Annual Income (spousal income, child support, benefits, etc.)

Total Annual Household Income

I certify that the information provided is true and complete to the best of my knowledge. I agree to notify the clinic if my financial situation changes. I understand that providing false information may result in termination of financial assistance and responsibility for all charges incurred.