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.




Application for Assistance Form

Patient Authorization Form

Request for Assistance Policy Form

Assistance Locations

Virginia Counties: 

  • Buchanan

  • Dickenson

  • Grayson

  • Lee

  • Norton

  • Russell

  • Scott

  • Smyth

  • Tazewell

  • Washington

  • Wise

  • Wythe

Tennessee Counties:

  • Hawkins

  • Johnson

  • Sullivan

  • Washington