Medical Debt Assistance Request Form

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Medical Debt Assistance Request Form

Welcome! This form is designed to gather information to help us connect you with local and federal resources to assist in settling your medical debt. Our goal is to identify the best programs and agencies that can offer support based on your specific circumstances. Please fill out the form below, and a member of our team will get back to you as soon as possible.

Email *

Full Name (First & Last) *

Phone Number *

Address (Street, City, State, Zipcode) *

What is your current employment status?

Employed full-time

Employed part-time

Unemployed

Other:

Clear selection

Household Income (Annual)

Less than $20,000

$20,000 - $40,000

$40,000 - $60,000

$60,000 - $80,000

$80,000 - $100,000

Over $100,000

Prefer not to answer

Clear selection

Total Amount of Medical Debt

Less than $1,000

$1,000 - $5,000

$5,000 - $10,000

$10,000 - $20,000

Over $20,000

Clear selection

Have you already received any assistance with your medical debt?

Yes, from a government program (e.g., Medicaid, Medicare, etc.)

Yes, from a non-profit organization

Yes, from a private debt management company

No assistance received yet

Clear selection

Do you have any specific medical debts that you need help with? *

Are you currently enrolled in any public assistance programs? (Select all that apply)

Medicaid

Medicare

SNAP (Supplemental Nutrition Assistance Program)

TANF (Temporary Assistance for Needy Families)

SSI (Supplemental Security Income)

VA Benefits

Option 7

None

Other:

Required

What is the best way to contact you?

Phone

Text Message

No preference

Clear selection

Additional Comments or Questions

Clear form

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