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The Upside Fund Medical Assistance Application
Application form for individuals seeking financial assistance for medical expenses
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
Phone Number
*
Your answer
City and State of Residence
*
Your answer
What diagnosis or condition are you receiving (or have received) treatment for?
*
Your answer
Please briefly describe the treatment, procedure, or care you are seeking assistance with.
Your answer
What healthcare provider, hospital, or medical facility is providing your care?
Your answer
What is your total annual household income?
Your answer
How many people live in your household?
Your answer
Are you able to provide documentation (tax return and/or pay stubs) verifying your household income?
Yes
No
Clear selection
What is the total dollar amount of medical bills currently owed or expected to be owed for this treatment?
Your answer
Are you able to provide documentation verifying your diagnosis and the amount owed?
Yes
No
Clear selection
Do you currently have health insurance?
Yes
No
Clear selection
If insured, has your insurance company
approved
coverage for any portion of the treatment or expenses?
Yes
No
Not Applicable
Clear selection
If insured, has your insurance company
denied
coverage for any portion of the treatment or expenses?
Yes
No
Not Applicable
Clear selection
If you do not have health insurance, have you pursued other financial assistance programs or resources?
Yes
No
Not Applicable
Clear selection
If not, would you like assistance identifying additional financial assistance resources that may be available to you?
Yes
No
Clear selection
Please share how your diagnosis, treatment, or medical expenses have affected you and your family.
Your answer
If you receive a grant, would you be willing to share your story or serve as an ambassador for The Upside Fund and its mission?
Yes
No
Maybe - I'd like more information
Clear selection
Is there anything else you would like us to know?
Your answer
Applicant Certification: I certify that the information provided is true and accurate to the best of my knowledge.
*
I Agree
Date of Submission
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
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