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BEFORE YOU BEGIN: You will need copies of your bills to complete this application. If you don’t have them handy, we will reach out to you to complete your submission.

Please complete all sections truthfully. If information is found to be misleading, false, or inaccurate it will result in a disqualification of the application. Verification of income, diagnosis, and treatment must be provided with application. All documents may be uploaded through web application tool. Cellphone photos of documents will not be accepted. They must be scanned in or may be faxed to our office 330.835.5978.