Medical form with stethoscope

Patient Information

If you are in need of assistance…
To formally apply for assistance from the Foundation, download and fill out ALL THREE forms linked below and fax or mail them to our office. You will be contacted by our Patient Advocate once the information is received.

Get In Touch
 

Forms

 

Application for Assistance Form

Click Here

Patient Authorization Form

Click Here

Request for Assistance Policy Form

Click Here

Assistance Locations

Virginia Counties: 

  • Buchanan

  • Dickenson

  • Grayson

  • Lee

  • Norton

  • Russell

  • Scott

  • Smyth

  • Tazewell

  • Washington

  • Wise

  • Wythe

​

Tennessee Counties:

  • Hawkins

  • Johnson

  • Sullivan

  • Washington