Letter of Support for Individuals with No Income

Name: AccelHealth
Price range: $

If you receive support, for example food, housing, or financial support, from a family member or friend,
have the person who provides support complete this letter for you to receive the sliding fee discount.

Supporter Information

If the person you are filling this form out for lives with you, we will need copies of your monthly income
for them to receive the discount.

Date: ___ / ____ / _____

I, __________________________, provide __________________________

Supporter’s Name and Patient’s Name

Patient Address: ________________________________________________

Services Provided

Check all that apply:

Food
Housing/Rent
Financial Support
Other: ________________________________________________

Supporter: The person I am providing support for does does not live with me.

Check one

I believe the monthly, dollar value of these services to be approximately $_________

Supporter’s Phone: _________________________________________________

Supporter’s Address: ________________________________________________

Relationship to Patient: _____________________________________________

Supporter’s Signature: ______________________________________________

Additional Comments

_____________________________________________________________________________________________

_____________________________

________________________________________________________________

_____________________________________________________________________________________________

State: ___________

City: ___________

Zip: ___________