Get Healthy Grant Application

Get Healthy Grant Application2018-08-15T16:47:22-05:00
  • Date Format: MM slash DD slash YYYY
  • 1) This is the AGI on line 37 of form 1040.
    2) If you are claimed as a dependent on someone elses tax return, please enter the AGI for that return.
    3) You will be asked to verify this income.
    4) You are not eligible for the grant, if you did not file taxes for last year or were not a dependent on someone elses tax return.
  • YOU MUST SUMBIT ONE OF THE FOLLOWING OR YOU WILL NOT BE ELIGIBLE.
    a. your last Federal tax return (Page 1 only of Forms1040, 1040A or 1040 EZ – no attachments, W-2 forms or pay stubs)
    b. an eligibility letter from the US Dept. of Health and Human Services for Temporary Assistance for Needy Families (TANF) or General Assistance (GA);
    Please blacken out your SS# on these forms.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf.
  • Please enter the exact study, body part and protocol on your order.
  • Please upload a copy of the physician referral or order for your study. A photograph from a smart phone is sufficient as long as it is readable.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf.

Instructions

1. Please complete application accurately. You will not be allowed to resubmit application or change data once submitted.
2. You will be asked to verify income if your application is approved.
3. Grant applications are reviewed within 1 week of submission.

Support

For support call 1-855-346-5152. We are open Monday-Friday  8:30am – 5:00pm.