Skip to Main Content

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, the application will be disqualified.

Verification of income, diagnosis, and treatment must be provided with application. Remittance documents must be legible and include all of the following or they will not be accepted: Full account number, name and address of applicant, company and mailing address, amount due. Documents may be uploaded using the form below or faxed to our office at 330-835-5978.