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:

• Gross salary

• Unemployment compensation

• Disability and Worker’s Compensation

• Social Security/Supplemental (SSI) benefits

• Public assistance (TANF, SNAP, etc.)

Please submit a copy of the first page of your most recent tax return or W2. If you are unable to provide income documentation, please elaborate on your source(s) of income and why you are unable to provide your tax return:

Upload a W2 or most recent tax return:

If you are unable to provide income documentation, please elaborate on your source(s) of income and why you are unable to provide your tax return here:

I certify that:*

I understand that, provided I meet eligibility criteria, my cost for testing will be limited to $0 if my income is up to 2x the federal poverty level; $0-100 if my income is 2-3x the federal poverty level; or $100-295 if my income is 3-4x the federal poverty level.

The information provided by myself or my legal representative is true and accurate.

I have read and understand the requirements of the NxGen MDx Access for All Program and understand that at any time, NxGen MDx reserves the right to modify or terminate this program and to audit the information I have provided.

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