Application

All information I have provided is true and accurate. I understand that any financial assistance provided by the AOF is provided directly to my creditors, is limited, and is based on the immediate needs that negatively impact my health status. I understand this application will expire six months from date of the submission. Providing false information will result in denial of assistance.

I authorize the AOF to contact my health care provider(s) listed above, and I authorize my health care provider(s) to release information to the AOF related to this application. If requested by my health care provider(s), I will complete an appropriate authorization to allow him/her to release information to the AOF pertaining to this application. All information provided to the AOF will remain confidential, except that the AOF may disclose information to my creditors and others as may be necessary to provide financial assistance.

I fully understand that AOF’s funds to provide assistance may be limited and that I should coordinate a plan for long term financial support by contacting additional community resources.

I understand that although the AOF may consider billing cycles and due dates when providing financial assistance, I remain fully responsible for timely payments of my debts, and I will indemnify and hold harmless the AOF for any expenses, losses, or liabilities arising from or related to my debts.