Please complete the application below. All required fields must be completed in order to be considered.
If you have any questions, please contact Jennifer Parker at jparker@factrelief.org.

 

APPLICANT INFORMATION

Please complete for the person who has been diagnosed with an illness or suffered an injury.
Patient or Injured Person

ILLNESS OR INJURY INFORMATION

FINANCIAL / INSURANCE INFORMATION

ADDITIONAL MONTHLY EXPENSES RELATED TO YOUR ILLNESS OR INJURY THAT ARE NOT COVERED BY INSURANCE/MEDICARE/MEDICAID

FACT Relief facilitates direct payment of eligible expenses and does not direct funds directly to patients or their families.