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Health For All Patient Waiver Application

We understand money can be tight. If you cannot pay the fee, please fill out this form to request that your fee be waived. Approval is based on financial need and availability of resources.

Please know:
- Filling out the form does not mean it will be approved
- If it is approved, we will tell you and you will not have to pay
- If you can pay a smaller amount (like $5 or $10), please let us know — every bit helps.

Thank you.
1.Full Name:(Required.)
2.Date of Birth:(Required.)
3.Phone Number:(Required.)
4.Email Address:(Required.)
5.Number of people in your household:(Required.)
6.Estimated monthly household income:(Required.)
7.Do you currently receive any of the following?(Required.)
8.Briefly explain your current financial situation or hardship:(Required.)
9.I certify that the information provided above is true and complete to the best of my knowledge. I understand that this application does not guarantee a waiver and that I may be asked to provide documentation if needed.
Please sign by typing your full name.(Required.)