Apply For Help

Please open and print each of the forms below. Fill out by hand and fax, mail or hand deliver the paperwork to us. Please DO NOT send by email, as it is not a safe or HIPAA compliant delivery method. If you are unable to print the paperwork, please contact us at 865-250-8812.

Application For Assistance (Mandatory)

Medical History Form (Mandatory)

Patient Information Form (Mandatory)

HIPAA Authorization Form (Mandatory)

Authorization For The Use of Image (Optional)