ASK FOR HELP
Request for Assistance (Please Read Carefully)
THE REQUEST FORM BEGINS ON THE NEXT PAGE.
FOLLOWING ARE DIRECTIONS TO HELP YOU COMPLETE IT FULLY.
This form is best viewed and completed on a laptop / desktop computer. The instructions for each field are situated to the LEFT of each field, which means on a phone or tablet, the instructions are not situated next to the fields they are related to. Attempting to complete this form on a phone will likely result in errors which are likely to delay your Request for Assistance.
When asked for a number value, please input whole numbers (1000). Do not enter special characters (-,!,$,#,@,%,&,*). Do not enter commas or cents. Round up to the nearest whole dollar.
If you were given a range for the cost of treatment, we encourage you to enter the Highest end of the range only. Ranges do not save properly.
Do not elaborate in most fields, please enter only the information requested. If you have additional information to provide, please add that information into the free-form Description field.
Do not leave fields blank. The form allows you to save it without complete information, but it will delay and even cause us to deny your Request for Assistance. Without a complete picture of your situation, we are unable to match your Request to the proper Funding Program to assess whether or not we can assist.
To begin the Request, please click Continue now.