Confidential Client Assistance Application
* All sections, including income, must be completed to be considered for assistance
Participant Name
Date of Birth
Age
Parent/Guardian Name (if minor or in care of adult)
Address
City
Zip
Email
Cell Phone
Diagnosis
Pertinent Medical Information
Is the participant currently receiving medical services? Please describe:
Please describe why you feel the participant should receive this additional assistance. (May attach additional page if needed)
Household Monthly Income Information (mark 0 if no income from this source)
Employment
Unemployment
Disability
Social Security
Public Aid
Child Support
Alimony
Other
Describe Other
Insurance Information
Insurance Company
Medicaid Number (if applicable)
Family History
Number of siblings in household and ages of siblings
Participant Digital Signature (if independent adult)
Parent/Guardian Digital Signature (if dependent adult or minor)
Date
Contact Information