Financial Assistance Request Application

* Required.

Request for Financial Hardship is based upon

Primary Insurance Information

Secondary Insurance Information

Supporting Documentation

*** Please see the section below on what types of supporting documentation are required to support your application.

I, (parent/guarantor), hereby certify that the above documented information is true to the best of my knowledge. I further confirm that should a significant change in financial hardship occur, I will notify Strive Medical and revise this application.

Acceptable Documentation for Hardship Application

Supporting Documentation:

*** In order to process your application, you will need to email us supporting documentation. Please email Please see the list below for appropriate types of documentation.

Documented proof of financial hardship can include but is not limited to:

  1. W-2 withholding statements

  2. Paycheck stubs

  3. Income tax return

  4. Forms from Medicaid or other State-funded medical assistance

  5. Forms from employers or welfare agencies

  6. Proof of unemployment

  7. Proof of personal bankruptcy settlement

  8. Other documentation that shows you would be unable to pay medical bill and still be able to pay for other basic or necessary expenses