Patient Assistance Request Application

Household financial information (required)

Documentation of household income (required)

Please attach copies of whichever of the following best show the income reported above:

1. Federal tax return from the most recent year (pages 1 and 2; your SSN may be crossed out). A tax return is preferred but not required.
2. OR Medicaid information (Medicaid beneficiaries)
3. OR any combination of: one month of paycheck statements from the most recent month (must show year-to-date gross income); Social Security statement of benefits (SSA-1099 or 4506-T); pension, annuity or retirement statements (1099-R); most current bank statement (complete month, pre-printed with the account owner’s name; only the account number may be crossed out).

We cannot process your application until documentation of household income is received. You can take clear photos with your phone and attach them below, or fax them to 1-800-886-4201 (Attn: Intake Dept.) or mail them to 8988 East D Avenue, Richland, MI 49083.

Special circumstances (optional)

Describe any special financial circumstances and/or medical expenses you would like us to consider that affect your ability to pay for your pneumatic compression device. Medical expenses must be listed with dollar amounts to be considered.

Certification

I certify that all information is true and correct to the best of my knowledge. I understand that Midwest Compression is relying upon this information to determine my financial need. I provide this information in strict confidence and direct that it be used by Midwest Compression to determine my ability to pay for the equipment and services provided by Midwest Compression. I understand that no promise of reduction or waiver has been made and that only authorized staff may respond to this request.