Patient Financial Assistance Program

We offer a Patient Financial Assistance Program for those who are uninsured or who meet certain federal income requirements based on household/family size and the Department of Health and Human Services (HHS) yearly Federal Poverty Levels (FPL). You can view the current year’s FPL here. If you make more than 400% of the FPL, you will not likely qualify for assistance.

To Apply:

Fill out the form below making sure to include full name and date of birth for all family members in your household as well as a copy of the most recent year’s tax returns for all adults in the household.

If you prefer, you are welcome to bring the same documentation to the clinic in person.

Please note: Assistance is offered on a year to year basis, and expires at the end of each calendar year.  We encourage you to re-apply at the end of the year by sending us another message with a copy of your most recent tax return and any noted changes on household size.