How did you hear about our Charity Program?
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What other sources of assistance have you applied for?
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What other means have you exhausted in trying to raise money?
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Have you received any additional funds from these resources?
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Do you have insurance? If so, what kind?
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How has this medical condition affected your life? What adjustments are you having to make?
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What is your treatment plan? Send us a letter from your doctor if you have one.
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Please provide any additional information that you think the Association needs to know to consider your request:
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Please provide a specific list of all other charity care for which you have applied:
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Please describe your personal situation and reasons for requesting assistance.
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