Financial Assistance Request Application
Acceptable Documentation for Hardship Application
Supporting Documentation:
*** In order to process your application, you will need to email us supporting documentation. Please email ptcollections@strivemedical.com. Please see the list below for appropriate types of documentation.
Documented Proof of Financial Hardship can include But is Not Limited to:
- W-2 withholding statements
- Paycheck stubs
- Income tax return
- Forms from Medicaid or other State-funded medical assistance
- Forms from employers or welfare agencies
- Forms from employers or welfare agencies
- Proof of unemployment
- Proof of personal bankruptcy settlement
- Other documentation that shows you would be unable to pay medical bill and still be able to pay for other basic or necessary expenses
* We will contact you using the information you provide in the form above. Thank you.