Submit Application for Financial Assistance - Desert Star Institute for Family Planning, Inc

Apply for Financial Assistance

Desert Star Institute for Family Planning, Inc., understands that sometimes people face financial challenges, and we are here to help. We have partnered with the Rooted Doula Collective, to provide financial assistance to qualified clients of the collective.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
What is the best time to reach you?*
Our program assistant will contact you to review your application and determine your eligibility.
- Morning
- Afternoon
- Evening
Birthdate*
Date Format: MM slash DD slash YYYY
Gender Identity*
Household Information*
Please provide the number for each column of adults and minors in the first columns and the total in the last column.
Number of Adults in Household Number o Minor Children/Dependents Total Number in household
Do you have health insurance?
Private health insurance or insured through Employer*
- Yes
- No
Medicare*
- Yes
- No
AHCCCS (Medicaid)*
- Yes
- No
If yes, does your insurance cover doula services?*
- Yes
- No
Uninsured*
- Yes
- No
Please list your MONTHLY gross household income (Income before taxes or deductions) calculated for all household members Age 19 or older
Pay, Wages, or Salaries Tips Unemployment benefits
Social Security Benefits Public Assistance Benefits (TANF) Disability, workers compensation, or other payment for an injury or illness
Retirement or pension benefits Alimony or child support payments Insurance or annuity payments to me

Interest or dividends from savings accounts or investments or any withdrawals from these accounts	Rental income or other income from a Business	Income from royalties, patents, gambling, or lottery winnings

TOTAL COMBINED MONTHLY HOUSEHOLD GROSS INCOME*
Patient Attestation:
I attest that all the information that I have provided to determine my eligibility for financial assistance for doula services is complete and correct to the best of my knowledge. I understand that I cannot request reimbursement for any services rendered through the doula access program from any government program or third-party insurer. I further agree to notify the doula of any changes in my income or insurance, or other factors used to determine my eligibility status were I to receive financial assistance in the future. I authorize the release of my Protected Health Information (PHI) for this patient assistance program or any third parties retained to administer the program and who may audit my PHI for the purpose of verifying my eligibility.
Printed Name*
First Last
Signature*
Date*
Date Format: MM slash DD slash YYYY

Number of Adults in Household	Number o Minor Children/Dependents	Total Number in household

Social Security Benefits	Public Assistance Benefits (TANF)	Disability, workers compensation, or other payment for an injury or illness

Retirement or pension benefits	Alimony or child support payments	Insurance or annuity payments to me

Pay, Wages, or Salaries	Tips	Unemployment benefits

Apply for Financial Assistance

Do you have health insurance?

Please list your MONTHLY gross household income (Income before taxes or deductions) calculated for all household members Age 19 or older

Patient Attestation: