Submit a Financial Assistance Determination Appeal Patient Name First Last Person Responsible for Paying Bill (if not the patient): First Last Address Street Address City State Zip Phone NumberDate of ServiceDate of Determination LetterReason for the DenialSelect Denial ReasonOver IncomeDetermination Percent ReviewProof of Income Not SubmittedZero Income Letter Not SubmittedMinor Child Parent Information Not SubmittedPlease provide why you believe your initial financial assistance determination was incorrect.Document UploadPlease upload documents such as pay stubs, bank statements, tax returns, and other income statements to support your appeal. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 30 MB. Please do not close your browser or leave this page until you see the confirmation page.EmailThis field is for validation purposes and should be left unchanged.
