How Do I Qualify

You will need to provide documentation from a physician’s office confirming that you are in need of the proposed procedure. In addition, please fill out the form below, confirming that you are in the correct economic status to qualify for financial support (additional documentation may be required as needed). Once approved, the physician’s office will schedule the procedure within their primary facility of practice. When necessary, the Patient Benefit Foundation may assist in helping transport the patient to the location of the procedure when they have no alternative options.

Are you a patient in need of elective surgery?

Complete our application to have your procedure qualify for funding by our generous contributors.