Please be prepared to include the following documents with your application:

  • Past three months’ bank statements for all accounts.

  • Latest Federal Income Tax Return, including W-2 Earnings Statements.

  • Payroll check stubs, bank statements, or other documentation of monthly income, sources reflecting income, of all responsible parties for at least the three months prior to application.

  • If applicable, please provide a statement of monthly benefit from Social Security or other retirement or disability benefits.

  • Copies of rent or mortgage payments and utility bills.

  • If applicable, please provide Medicaid/Medicare Approval/Denial Letter, Denial of Unemployment or Workers’ Compensation Benefits.

  • Valid state issued identification, a utility bill received within the last 60 days, a lease agreement, vehicle registration card, or mail addressed to patient from a local State or Federal Government entity.

  • Copies of any other supporting documentation you feel should be included.

After Submiting Your Application

We will send you a letter once your application has been reviewed and a determination is made.

For more information on Financial Assistance, please call Patient Financial Services at 1-877-636-2261 or email