Financial Assistance

Fill out our application form below for financial assistance

Financial Assistance Application Form

Personal Information:

First Name*

Last Name*

Date of Birth*

Address*

Phone*

Email*

Financial Information

Are you currently employed?*

Yes

Monthly Household Income (After Tax)*

Number of Dependents*

Monthly Expenses*

Reason For Financial Assistance*

What type of financial assistance are you requesting?*

One time fee reduction

Past due balance forgiveness

Ongoing monthly assistance

Amount Requested*

Additional Information

Do you currently receive assistance from any government funded programs such as; Medicaid, SNAP, Cash assistance?*

Yes

Do you receive any other forms of income, including Disability, Social Security, Child Support?*

Yes

Do you currently have Medical Insurance Coverage?*

Yes

Please provide any additional information you believe is relevant to your financial situation and need for assistance:

Please attach the following documents:

Most Recent Pay Stub
Government Assistance Documentation
Other Income Documentation
Insurance Card

I HEREBY SWEAR UNDER PENALTY OF PERJURY UNDER THE LAWS OF UNITED STATES THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE. I AUTHORIZE HIGHLIFE HEALTH, LLC (AND ITS CHILD COMPANIES) TO VERIFY THE ABOVE INFORMATION FOR THE SOLE PURPOSE OF ASSESING FINANCIAL NEED. I UNDERSTAND THAT IF I DO NOT QUALIFY, I WILL BE NOTIFIED AND WILL CONTINUE TO BE RESPONSIBLE FOR MY ENTIRE BALANCE. I AGREE TO NOTIFY HIGHLIFE OF ANY CHANGES TO THE INFORMATION PROVIDED IN THIS APPLICATION.

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