Patient Financial Assistance Application

The FoundationAccessTM Program offers direct support and guidance during each step of the billing process for our tests.

Financial Assistance is available to domestic residents of the United States.

Patient Information
Ordering Physician And Facility Information
Total Gross Annual Household Income
$
Please Advise Of Any Extenuating Circumstances That You Would Like Us To Consider

(Please advise of any extenuating circumstances that you would like us to consider. Select all that apply)

Who should we contact with the approval decision?

(Ensure contact information for patient and practice is filled in at the top of this form)

Patient
Practice
What's the patient's preferred method of communication?
Phone
Email
Mail
What's the practice's preferred method of communication?
Phone
Email
Mail
Fax

I am the patient
I am representing the patient
Acknowledge and sign in the signature box below
I hereby confirm that the above information is true, complete and accurate. I consent to the use of the above information as part of the FoundationACCESS Program.

* As a Personal Representative of the patient, or an Ordering Physician completing this application on my patient's behalf, my signature also certifies that I have explained to the patient the nature and purpose of this application and that the patient has consented to my completing the application on his/her behalf.

Please use your mouse to sign.