I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local
assistance for which I may be eligible to help pay my medical expenses. I understand that the information provided may be verified, and I
authorize Amberwell Health to contact third parties to verify the accuracy of the information provided in this application. I understand that if I
knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the medical bill(s). I grant Amberwell Health permission to contact me using any method
provided on this application.