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Financial Support Documentation
Financial documents must clearly state bank name and logo, account number (partial is acceptable), account holders name, date of statement, and account balance
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Patient Financial Assistance Application
Ensure contact information for patient and facility is filled in at the top of the form. Patient. Practice. Check all that apply: Email. Phone. Mail. Email. Fax.
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Financial Documents
Each financial sponsor (petitioner, any joint sponsors, and any household members) must submit an Affidavit of Support as well as evidence of their finances.
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