AccelHealth

LETTER OF SUPPORT FOR INDIVIDUALS WITH NO INCOME


If you receive support (e.g. Food, Housing, Financial Support) from a family member or friend please, have the person who provides support complete this letter for you to receive the sliding fee discount.

Supporter: 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.

MM slash DD slash YYYY
Hidden
Patient Address(Required)
With the following services (Check all that apply)(Required)
The person receiving support lives with me.(Required)
Supporters Address

THANK YOU FOR CHOOSING ACCELHEALTH!