Before You Start
1.) Print and sign the Release and Liability Form By Clicking Here... You will be required to upload it during the application process.
2.) Have a note ready from your physician's office that explains your diagnosis, prognosis, time frame of treatment and likely outcome.
3.) If you are requesting assisting with a bill please have the bill ready to upload during the application process.
Once you are ready to complete the application click the link below. The application should only take a few moments to complete.
Once you have completed your application you will receive a confirmation email. At this point we start the review process of your application, which includes contacting your physicians office for verification purposes. An Adipsy staff member will touch base with you within a reasonable time in reference to your application status.