Get Myriad Financial Assistance Program Application Uninsured Patients 2016-2025
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How to fill out the Myriad Financial Assistance Program Application Uninsured Patients online
Filling out the Myriad Financial Assistance Program Application for uninsured patients can help you access the financial support you need. This guide will provide step-by-step instructions to assist you in completing the application accurately and efficiently.
Follow the steps to complete your application online.
- Press the ‘Get Form’ button to obtain the application form and open it for editing.
- In the Patient Section, enter your name in the format Last, First, Middle. Ensure you provide your Social Security Number and Date of Birth accurately.
- Certify that you do not have any health insurance coverage, including state or federal programs such as Medicare or Medicaid.
- Indicate the number of people currently in your family household.
- Provide your gross annual household income. Remember, you must attach supporting income documentation, such as an IRS Form 1040. If an IRS Form 1040 is unavailable, include a brief letter explaining your income source.
- Confirm that your gross annual household income meets the financial guidelines established by Myriad Genetic Laboratories, Inc. You can find this information on their official website.
- Sign and date the application, certifying that the information provided is true and accurate. Print your name below your signature.
- In the Healthcare Provider Section, ensure that an accurate and completed Myriad Test Request Form (TRF) is attached. The patient's specimen must also accompany the TRF and this application.
- The healthcare provider must verify that the patient meets the medical criteria for the tests ordered on the TRF. Include the provider's signature, date, and printed name.
- After completing all sections, review the application for accuracy. You may now save any changes, download a copy, print the form, or share it as needed.
Complete your Myriad Financial Assistance Program Application online today to access critical financial support for your healthcare needs.
Myriad financial assistance is a program that provides support to patients who cannot afford testing costs due to lack of insurance coverage. This program is tailored to assist uninsured patients, making essential genetic testing more accessible. Through the Myriad Financial Assistance Program Application, patients can easily apply for the support they need.
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