Affordable Care Application
Our Applications Are Closed For 2024 & Will Reopen In January 2025.
You will find the Take Care Health and Wellness Financial Assistance Application attached. Completion of this application will enable us to present your account for consideration of financial assistance for your physician, services, or health care bill(s). This is for your Take Care Health and Wellness outstanding balances only.
We understand your desire for privacy. Accordingly, except for verification purposes, the information included in your application will be treated as confidential information. It will only be shared within Take Care Health and Wellness on a need-to-know basis.
Please complete each item on the application. If you need additional explanation space, please utilize the comment box at the bottom of the form.
*If you need help completing this application or there is an unclear area, please call our team.
All parts of the form must be filled out to be considered for our Affordable Care option.
We have a limited number of funds each month and while we aim to serve all who apply, we are not always able to do so. We will confirm with you (per the timeline below) if you have received funding for care, and if you have not, we will further advice whether we believe you should reapply or if we have automatically added you to next month’s waiting list.
All appointments are offered at a flat $20 fee. If you no-show an appointment or cancel/reschedule the appointment in less than 4 hours of your chosen time, you will be required to book another appointment with a second $20 charge.
You will be sent the confirmation that you have the option to book with your dedicated provider, via a special service link that will only charge you $20 for your appointment.
Once your dedicated provider reaches out to you to confirm your application was chosen for the Affordable Care program, all communication must be managed directly with that provider there on out.