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Unity Outreach Financial Assistance Application
Name
*
Name
First Name
First Name
Last Name
Last Name
Date of Birth
*
Phone
*
Email
*
Street Address
*
City
*
State
*
Zip Code
*
Country
*
Purpose of request? Briefly describe current need for assistance.
*
Do you have an immediate need?
*
Yes
No
How were you referred
Do you have income?
Yes
No
Do you currently receive any assistance?
*
Yes
No
Have you applied for assistance elsewhere?
*
Yes
No
If yes, where?
If yes, what were the results?”
Do you have health insurance?
*
Yes
No
If yes, what company?
If yes, what is your co-pay amount
If you have insurance, does it cover prescriptions?
Yes
No
If yes, what is your prescription co-pay amount?
What is your doctor’s name and phone number?
*
Pharmacy name and phone number?
*
Treatment center name and phone number?
*
Signature
*
Date
*
Submit
If you are human, leave this field blank.
