• Financial Assistance Program

    Please complete the form below to apply for the Financial Assistance Program
  • Important: Any missing information may delay the application process. Please be sure to fill out the application entirely and attach all supporting documents.

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  • In order to process this application, we need a few details. 

    Please tell us your household size and monthly income:
    The number of family members (including you) who live in your home. May include a spouse or qualified domestic partner, children, a non-parent caretaker relative, etc.  

     

  • Healthcare costs: Total out-of-pocket expenses you had over the last 6-months for medical services relating to gastroenterology care from a health care provider based in North Florida. May include copays, deposits, coinsurance, or deductible payments for eligible medical services.

    EMAIL
    Foundation@BorlandGroover.com

    FAX
    904-483-5874

     

  • Tax Documentation: Please provide the most recent income tax return.

    Email or fax this information to us at:

    EMAIL
    Foundation@BorlandGroover.com

    FAX
    904-483-5874

     

  • If you are uninsured, the Borland Groover Foundation may be able to help. 

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