Patient Financial Assistance Application

All information will be kept confidential and used only for review purposes.

Assistance Application Form

Personal Information

First Name

Middle Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Medical Information

Diagnosis / Mobility Condition

Are you currently working with a clinician or PT/OT?

Yes

How would a Matia Mobility device benefit your daily life?

Financial Information

Annual Household Income

Number of People in Household

Are you currently receiving any government assistance (SSI, Medicaid, VA, etc.)

Yes

Please provide details

Upload supporting documentation (e.g., tax return, SSI/SSDI letter, or pay stubs)

Choose File

Funding Request

Have you received other sources of funding?

Yes

Please list

How much can you contribute toward the device cost?

How much are you requesting from the Foundation?

Content & Certification

I certify that the above information is accurate to the best of my knowledge. I understand that funds are limited and awards are based on financial need and application volume.

Signature

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