Patient Scholarship Fund

What It Is

As part of our ongoing efforts to heal as many people as possible, we've created the Rising Health Patient Scholarship Fund. This scholarship fund will go towards those who are in need of our services but not in a financial position to do so.

How To Apply

We invite anyone in need to apply for this scholarship, and our clinic will thoughtfully vote on who will receive the funds. Anyone who wishes to contribute to this fund can do so at the end of their appointments here at the clinic. Thank you!

1. No out-of-state clients shall apply

2. No non-established clients may apply. The patient must have their first appointment and receive a treatment plan.

3. No lab costs shall be subject to hardship.

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Income Qualifications

Financial Hardship Application Form

Rising Health Specialty Clinic locations abide by the contractual and legal obligations of health benefit plans to collect charges, co-pays, coinsurance, and deductible amounts owed by patients. Recognizing that circumstances may arise where an individual is unable to pay in full at the time of service, we have adopted a policy of screening requests for discounts, delayed payment plans, or forgiveness of debt based on individual circumstances. To do this, we must ask for certain financial information. All information will be held confidential according to our privacy policy. Please provide the documents listed below for each adult family member, and complete this form to the best of your ability. Thank you!

Patient Information

Patient First Name

Patient Last Name

Date Of Birth

Phone

Number of dependents in household

Employment Information

Current employer

Employer phone number

Employer address

Current employer

Employer phone number

Employer address

If unemployed, please state when employment was terminated. If lay-off is temporary, indicate expected duration:

Assistance Received

State financial assistance: Monthly income (after payroll deductions)

Please upload a copy of last year’s federal tax return

Upload File

Monthly expenses (not including payroll deductions)

Medical expenses for previous calendar year

Please upload copies of the two most recent payroll stubs or unemployment benefit payments

Upload File

Any additional comments you'd like to add

By signing below, I certify that this information is true and complete. I grant this office permission to verify the information, and I acknowledge that completion of this form does not guarantee discount, payment plan or forgiveness of debt.

Patient Signature

Today's Date

Thank you for your application. Our team will review this and reach out to you if we have any questions.