Financial Assistance Application Form Instructions
Buckets of Love, Inc. partners with healthcare and mental healthcare providers to help you access mental health services, affordably. You may qualify for free care or reduced-price care based on your family size
and/or income, even if you have health insurance. Please view our financial assistance policy here.
To apply for Montana Medicaid, please go to https://medicaid-help.org/
In order for your application to be processed, you must:
- ♥ Provide us information about your family
- Fill in the number of family members in your household (family includes people related by birth, marriage, or adoption who live together).
- ♥ Provide us information about your family’s gross monthly income
- (income before taxes and deductions) to include pay stubs, W-2 forms, tax returns, social security award letters, etc.
- ♥ Provide documentation for family income and declare assets
- ♥ Attach additional information if needed
- ♥ Sign and date the financial assistance form
- Mail completed application with all documentation to: Buckets of Love, Inc., PO Box 3104, Missoula, MT 59806, or email it to firstname.lastname@example.org. Be sure to keep a copy for yourself.
- We will notify you of the final determination of eligibility within 30 days of receiving a complete financial assistance application, including documentation of income.
- By submitting a financial assistance application, you give your consent for us to make necessary inquiries to confirm financial obligations and information.
- You may receive bills from your provider until your application has been reviewed and approved.
- Please fill out all information completely. If it does not apply, write “NA”.
- If financial assistance is awarded, you will have 30 days to locate a provider that agrees to accept the terms of the application.
- If you prefer to turn in a paper application, please download the pdf here.