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

The Vivi Negrete Foundation will cover the costs associated with general medical care provided within the scope of its programs and services. However, if the patient requires a referral to a specialist or additional external medical services, the costs related to such consultations, procedures, treatments, diagnostic studies, or specialized follow-up care will not be covered by the foundation.

La fundación de Vivi Negrete cubrirá los costos correspondientes a la atención médica general brindada dentro del alcance de sus programas y servicios. Sin embargo, en caso de que el paciente requiera ser referido a un especialista o a servicios médicos externos adicionales, los costos relacionados con dichas consultas, procedimientos, tratamientos, estudios diagnósticos o seguimientos especializados no serán cubiertos por la fundación.

❌ 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