Medical financial assistance Medical Financial Application InstructionsSubmit completed application along with supporting documents. Only completed applications will be considered for review by the Medical Advisory Team (MAT). Prompt notification made after determination.How did you hear about Living to Win Foundation?* Living to Win Event Physician Internet Search Other Name* First Middle Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Employment Status Full Time Part Time Self Employed Unemployed Student Employer Contact Information Next of Kin* First Last Total annual household income* NMO Diagnosis:*Max. file size: 32 MB.A physician's letter stating diagnosis date and current treatment will need to be uploaded. Financial Assistance Required* Treatment Transportation Rent/Mortgage Utilities Groceries Automotive payment Other Has other assistance been exhausted including insurance? Please explain.*Have you ever received financial assistance from L2W?* Yes No Please provide the date* MM slash DD slash YYYY Signature* Reset signature Signature locked. Reset to sign again Date Submitted* MM slash DD slash YYYY
