Application for the Access for All Program

Name*

First

Last

Date of Birth*

day

month

year

Phone*

Email*

Insurance (Please select all that apply)*

I don't have insurance

I have decided not to use insurance to cover my testing

I have insurance but my estimated out-of-pocket responsibility will be more than I can afford.

I have submitted my insurance information to NxGen MDx

How many people are in your household? Your household size is the number of people you are financially responsible for. These people may include yourself, your spouse, your children.*

What is your household Annual Gross Income (AGI)?*

AGI includes the following for all members of your household:

NxGen must receive confirmation of the patient’s household income before providing assistance, including wages, social security, pension/retirement, dividends/interest, rents/royalties, unemployment, worker’s compensation, alimony, or other assets.

Please submit a copy of the first page of your most recent Federal tax return, Form 1040.

Upload your most recent Federal tax return, Form 1040:

If you are unable to submit income documentation, briefly describe your income source(s) and why your tax return is not available:

I certify that:*

I certify that I do not carry any U.S. Federal or state-funded health insurance (e.g. Medicare, Medicaid, Tricare, Medicare Advantage).

I certify that all documents I provided are true and correct copies and that all information contained in them and on this form is true and accurate.

I understand and agree that NxGen MDx reserves the right to, at any time without my notice, modify the application form, modify or terminate this program, or request any additional information.

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