Financial Assistance Application

Personal Information

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address*

Mailing Address

Street Address*

City*

State*

ZIP Code*

Provider Information

Clinic Name

Provider / Physician Name

Financial Information

Number of People in Household*

Annual Household Income (Pre-Tax)*

$

Extenuating Circumstances

Select all that apply. Each qualifying circumstance may increase your discount level.

Retired (i.e., fixed income)Short or long-term disabilitySignificant medical expensesSupporting family member(s) outside of householdAlimony and/or child supportLoss of income due to diagnosis or treatmentNon-local travel expenses for treatment (e.g., hotel, airfare)Other

Patient Attestation

I confirm that I do not carry any U.S. federal or state-funded health insurance (e.g., Medicare, Medicaid, Tricare, Medicare Advantage). *I hereby certify that the information provided is true and accurate. I understand that BillionToOne reserves the right to modify or terminate this program, audit my information, or request additional documentation. *