If you or a loved one have been diagnosed with Parkinson's Disease, you may apply for financial assistance from us. To do so, fill out our application form as completely as possible. You can submit the form right here online, or you can download the form (click here to view and download the pdf), fill it out, and email it to us.
If you are submitting online, we suggest you first review the form to see what information is asked, gather that information, and then come back here to complete the form. You will need to provide:
Personal contact information.
The name, practice name, and address for your neurologist / movement disorder specialist and your primary care physician.
When you were diagnosed (month and year) and your age at diagnosis.
Financial information: annual income, estimated net worth, monthly expenses.
A short description of what you are asking for help with and why.
The application may be completed by someone else, such as a care giver or family member, on behalf of the person with Parkinson's/PSP, as long as they have been authorized to provide the required information.
Note: we are currently providing assistance to US citizens / permanent residents whose primary residence is in the state of Florida. If you are interested in assistance but you do not meet this criterion, please fill out our contact form, and we will reach out to you if and when we expand the locations we serve.
We value your privacy, and we treat your information as strictly confidential.
If you have any questions, you may contact us at [email protected].