A social worker, doctor, or other medical provider must fill out the application below on behalf of the applying patient. By applying you confirm that they meet the qualifying criteria outlined in our program guidelines.

Emergency Financial Assistance Application

MM slash DD slash YYYY
Provider Name(Required)
A social worker, doctor, or other medical provider must fill out the application on behalf of the patient.

Patient Details

Patient Name(Required)
Address(Required)
Must have a low income as defined by the U.S. Department of Housing and Urban Development (HUD) standards (income level of $76,750 or less).
Insurance Type
Checks will be made payable directly to landlord, utility company, phone, medical provider, etc. A gift card option is also available.
The maximum award granted is $250.

English