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Patient Financial Assistance Application
Patient Financial Assistance Application
Patient First Name
Patient Last Name
Date of Birth
Guardian's Full Name
Relationship to Patient
Patient Address
Email Address
Phone Number
Preferred Method of Contact
Phone
Email
Mail
Patient's annual gross household/family units income:
EVIDENCE: Please email (contact@bevelxlabs.com) one of the following forms of documentation:
Recent paycheck stub for each wage earner in your household/family unit, or
Other evidence of your household/family unit income
CERTIFICATIONS: please check each box below to acknowledge agreement:
The information submitted and provided for this application is complete and accurate
I understand that completion of this form does not guarantee financial assistance.
I certify that paying for the BevelX Labs testing would cause financial hardship.
I understand that this program is subject to change or termination by BevelX Labs.
I authorize BevelX Labs to use the information on this application to assess my eligibility for the financial assistance program.
I authorize BevelX Labs to contact me directly regarding this application.
I understand that these authorization documents can be canceled at any time by mailing a letter to BevelX Labs.
I certify that I have read and understand the Certifications and Authorizations above and that I agree to the above terms, as indicated by signing below (type your full name and date as signature):
Submit