alcure fee reduction application

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Email *

We use Google Workspace forms designated for medical practices. All your information is encrypted to HIPAA standards as you enter it and stored in our secure Google Cloud environment. It's kept strictly confidential and only used to determine eligibility for our fee reduction program.

Have you experienced a job loss or reduced income directly caused by the covid response economic restrictions? *

Yes

Tell us briefly what your occupation or job was that has been impacted by the covid response. *

Tell us briefly what, if any, substitute income or other relief you've been able to obtain (e.g. PPP loan, EIDL loan, other loan, home refinance, unemployment benefits, financial support from family or friends, another job or alternate source of income, rent or mortgage reduction or suspension of payments, etc.). *

If you have obtained substitute income, tell us briefly whether it has equalized the income you lost and if not, about how much of a disparity you have experienced. You can tell us your approximate amount of take-home income per month before covid restrictions and what it is now. Also, let us know approximately how much you've lost in income that you'll never get back, even with the substitute income you've obtained. *

What's your city and state? *

Is there anything else you would like us to consider in reviewing your application? *

What's your first name? *

What's your phone number? (optional)

How do you prefer we reach out to you? *

Please call me (if you provided your phone number).

Please email me only.

Either is fine (if you provided your phone number).

Send me a copy of my responses.

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