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

Patient Assistance Grant Form
  • Date Format: MM slash DD slash YYYY
  • (include primary and secondary, if applicable)
  • (Provide exact name of equipment/service; name of manufacturer or provider; and the name and contact information for the vendor. If available, please attach brochure and/or photos.)
  • Please research the cost of your item(s) before submitting your application. An estimated cost must be entered, or your application will be rejected.
    Please enter a number greater than or equal to 1.
  • Single PDF containing all supporting documentation (optional)
  • This field is for validation purposes and should be left unchanged.