Financial Assistance Program

Application Requirements

Required Documents:

1. Online Application
- One application per child if applying for multiple children

2. Financial Documentation
- Bills or quotes for which you are seeking assistance
- Quote(s) must be no older than 90 days
- Explanation of Benefits (EOB) from insurance provider

3. Medical Documentation
- Letter of recommendation from child's healthcare professional for all non-emergency requests
- Letter must include:
- Child's name
- Child's date of birth
- Diagnosis
- Description of service requested
- Medical necessity
- Cost (if known)
- Duration (if applicable)

4. Income Documentation
- Most recent pay stub from all working parent(s) or guardian(s)
- Most recent tax return(s)
- If no taxes filed: previous year's tax return and current W2(s) or 1099(s)
- If parent(s)/guardian(s) file separately: both tax returns required
- Important: Remove all SSN(s) from tax returns

5. Additional Documents
- If provider offers Financial Assistance Program: proof of application and denial letter (if denied)
- Upload additional tax returns in "Space for additional documents"

Submission

• Submit through online application portal
• Receive confirmation email once application is successfully submitted