Patient Assistance Grant Application
Your application packet should include the following documentation:
- Completed application
- A recent letter from the child’s physician or health care professional explaining the medical necessity of your request
- A letter of denial from the insurance provider stating that the requested equipment and/or service was denied (when possible)
- Proof of all income (including your most recent W2 form)
- Any other documentation pertaining to the nature of your request All information is kept confidential.
APPLICATIONS SUBMITTED PRIOR TO MARCH 1 WILL BE REJECTED