Special Needs/Disability Financial Assistance Application

Please complete the application for special needs/disability financial assistance.  You will need to have a Physician or Therapist note confirming the patient diagnosis to submit with the application. 

Upon receipt we will review and contact you in about 14 business days. 

    Patient Name

    Parent/Legal Guardian

    Additional family members residing in the home:


    Please check the services you are applying for:

    Physician RecommendationPatient/Caregiver CardDispensary Vouchers

    Please attach a Physician or Therapist note confirming diagnosis.


    Phone Number

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