Financial Assistance Application

We’re here to help. Flow Health is committed to providing easy and affordable access to our tests and services. Flow Health has established a patient access program to make certain all who need testing have access to our tests and that the cost does not create undue financial hardship.

PATIENT INFORMATION

Do you have health insurance?
First Name
Last Name
Date of Birth
Gender
Address
Street Address
Line 2
City
State
Zip Code
Preferred method of contact:
E-mail address
Phone numbers
ORDERING PHYSICIAN & INSTITUTION
Ordering Physician
Name of hospital or practice where you are being treated
Organization
PATIENT BACKGROUND
Estimated Gross Annual Household Income
Supported by the gross annual household income (including patient).
# of family members in household
Extenuating circumstances:
Provide additional context to your extenuating circumstances.
Please share any background you would like our financial assistance team to take into consideration when reviewing your application.
Write here...
By submitting this application, I am certifying that all information provided is truthful, complete, and I understand that financial assistance may be withdrawn if the information is inaccurate. I also consent to Flow Health’s use of the information to assess and/or verify eligibility for assistance.
Financial Assistance Application
We’ve received your application and it is being processed.
If you have any questions, our Billing team can be reached at 855.551.3789 between 7:00am and 7:00pm PT, Monday – Friday.
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