Haystack Financial Assistance Form

Financial Assistance Application

First Name

Last Name

DOB

MM/DD/YYYY

Mobile Phone

Email Address*

Address 1

City

State or Province

Zip or Postal Code

Do you have insurance?

Yes

Only Complete the following if you currently have insurance.

Insurance Company

Member ID

Group ID

Insurance Address

Insurance City

Insurance State

Insurance Zip

Salary Income

Social Security Income

Public Assistance

Savings or investment income

Other household income

Outstanding medical expenses

Extenuating Circumstances

Continuing out-of-pocket medical expenses that begin within the last 2 year

Childcare/eldercare expenses related to your diagnosis and/or treatment

Change in household income

Travel-related expenses for treatment

Loss or reduction of income due to diagnosis and/or treatment

Short- and/or long term disability status

Other

Total expenses related to extenuating circumstances

Number of adults in household

Number of children in household

Patient Signature

Please type in your full name. I certify that the included information is true, accurate, and complete.