PUSH Application

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(Your Name) Only employees of Urology of Virginia may submit this application on behalf of patients.
Name of Patient
Specific Assistance Requested
SURF offers this assistance to patients of Urology of Virginia to support NON-MEDICAL needs only. It is a one-time gift.
AUTHORIZATION TO SUBMIT ON PATIENT'S BEHALF
Please explain the request for funding.
Approval will be based on the following criteria:
*There may be other resources available through the "financial hardship" program at Urology of Virginia