Financial Assistance

You may apply for financial assistance by completing the secure application form below. Items marked by an * are required.

Explore our website and find the answers to the basic questions and then give us a call so we can discuss the more detailed aspects of the financial assistance process at MIMA. You will be contacted within 7 - 10 days.

First Name *


Last Name *


Birth Date *


Gender MaleFemale
Address *


City *


State *


Zip *


Phone*


Email *


Occupation


Employer


Income Range
0 Under $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 Over $50,000

Marital Status *
(Please Select) Single Married Separated Divorced Widowed

Race *
(Please Select) American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian

Number of Children Under 18
0 1 2 3 4 5 6

Funding Estimate ($Amount)


Have you received previous assistance from MIMA?* NoYes
Health Insurance Carrier


Do you have Medicare? NoYes
Diagnosis *



Diagnosis Date:*


Date of Last Treatment:*


Physician


Referred By


Personal Statement  *
Please tell us more about yourself, the situation you are in and what the grant would be used for.