Pregnancy & NICU

This form should be used if applying for assistance due to high-risk pregnancy, pregnancy complications, bed rest, hospital stay, or premature birth, NICU stay.

As of November 1, 2020, acceptable verification has to fall under one of the following categories:

  1. A healthcare provider verification form submitted online on our website at that is appropriately filled out by the third party with complete name, title, and contact information.
  2. A healthcare provider writing a letter on the appropriate letterhead and emailing said letter directly to us at The email must come from whoever wrote the letter and it must be from their official work email and include their full name and contact information in either the letter or the email.
  3. In cases of loss, documentation submitted or sent from either healthcare provider or parent applying that is official government or hospital paperwork. This may include a death certificate, the official paperwork that hospital completes for a death, or a detailed medical write up (not discharge paperwork) that shows the logo and contact information for the hospital or doctor as well as contact information for follow up.

Without the proper verification, we cannot process your application. We also reserve the right to follow up with those writing verifications for more information or to verify the validity of the verification. If we find after verifying that the information is not accurate, your application will be denied. If you have questions as to what is acceptable or have a different verification other than one listed, please do not hesitate to reach out and we can try to come up with a solution.

Note: If income information is not entered accurately, then we will not review your application.

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