You must check at least one to qualify for assistance *

I am a patient on dialysis receiving treatment at Laredo, TX and Zapata, TX?

I am employee requesting assistance on behalf of a dialysis clinic or a patient in Laredo, TX or Zapata, TX

Renal Professional Name *

First Name

Last Name

Renal Professional Phone

(###)

###

####

Preferred Patient Identifier (ex initials and date of birth or medical record number) *

First Name

Last Name

Receipt or Bill Submission *

I will email my bill or receipt.

I will submit my bill or receipt through a staff member at my clinic.