Please note that this is a two step application. Applications will not be accepted and reviewed until both steps are completed.
We are currently accepting applications from patients who reside in the following counties: Adams, Berks, Bucks, Chester, Cumberland, Delaware, Dauphin, Lancaster, Lebanon, Montgomery, Perry, Philadelphia, and York. If you do not live in one of these counties, please check back regularly as our goal is to continue to expand our reach.
Complete by Medical Professional
Please reach out to your medical team to complete the following portion of the application. Acceptable members of one's medical team include, but are not limited to: physicians, nurse navigators, primary care physicians, social workers, nurse practitioners, etc. If they have questions when filling out the application, have them refer to our FAQs, or contact us directly at email@example.com
Medical professionals: please download the travel statement form by clicking the button below. A completed statement will need to be uploaded, within the application, in a PDF format.
Complete by Patient (Parent/Guardian)
Please see the table below for a list of items to prepare for your application. Note that certain items are only required of certain family members, and that other items are only required if you intend to apply for opportunity costs.
|Driver's License / State ID||All Partipants 18+|
|Copy of Insurance Card||All Participants|
|Copies of Last Two Pay Stubs||Opportunity Cost Only|
|Copies of Last Three Months of Bank Statements||Opportunity Cost Only|
|W-2s of Any Working Non-Dependent Family Members||Opportunity Cost Only|