Patient Financial Assistance Application

The Vivi Negrete Foundation offers financial assistance to eligible patients. Please complete all sections of this form and attach the required documents so your application can be evaluated.

1 Patient Information

Full Name *

Date of Birth *

Phone *

Address *

City *

State / ZIP Code *

Email Address *

2 Household Information

Marital Status *

People in Household *

Number of Dependents

Total Monthly Income *

3 Employment Information

Current Employer

Position / Occupation

Employer Address

Gross Monthly Income

Years in Employment

4 Health Insurance

Have health insurance? *

Insurance Company / Plan

5 Approximate Monthly Expenses

Rent or Mortgage

Utilities (water, electricity, etc.)

Food

Transportation

Medical Expenses

Other Expenses

6 Required Documents

Please confirm the documents you will attach:

📄 Copy of Identification (Driver's License, Passport, or State ID) 💼 Pay Stubs (Last 2 Months)

📎 Click to attach documents

PDF, JPG, PNG accepted (max 10MB each)

7 Patient Declaration

I certify that all information provided in this form is true and complete to the best of my knowledge. I understand that the Vivi Negrete Foundation may request additional documentation and that providing false information may result in disqualification from the program.

Full Name (Signature) *

Date *

I confirm that I have read, understood, and agree to the declaration above. *

Your application will be sent to info@vivinegretefoundation.org

❌ There was an error. Please try again or email us directly at info@vivinegretefoundation.org

Financial Assistance Application

Patient Financial Assistance Application

Contact Info

(954) 217-1339

info@vivinegretefoundation.org