Medical Copayments or Prescriptions 2023-24

Medical Copayments or Prescriptions 2023-24

If you encounter financial circumstances that are above the standard cost of attendance, the university can sometimes help. Please use this form to describe your circumstances and attach supporting documentation. Please note that to provide funding, we must have documentation of the expense. Be sure to upload a copy of your bill and proof of payment with the button on the bottom of this form. If you have questions, please contact the office or provide information in the description below. If you are receiving Northwestern need-based scholarship, we will pay your insurance copayments. Because our ability to address your emergency funding request requires you to be a currently enrolled student, you should submit all requests in the term the expense occurs.

Please feel free to speak with a financial aid counselor if you have questions or need help completing the form. If you have specific concerns, please contact Adom Harris (adom.harris@northwestern.edu).

Please indicate your program type:

Please indicate your program type: Undergraduate Graduate/Professional
Please contact your Financial Aid Office. This form is for requests from Evanston undergraduate students. Please contact your financial aid office to explore your options. A list of office contacts can be found at https://www.northwestern.edu/sfs/about/contact/offices.html.
Your Name Your Name First Last
Your Student ID Number
Must be 7 digits. Currently Entered: 0 digits.
Your Email Address
Your Phone Number Your Phone Number - ### - ### ####
The expense that I am reporting was incurred during a time period I was actually enrolled. I understand I am not eligible to apply for emergency aid for an expense incurred while not enrolled (For example, reimbursement is not available for the summer term if I was not enrolled for summer.)

The expense that I am reporting was incurred during a time period I was actually enrolled. I understand I am not eligible to apply for emergency aid for an expense incurred while not enrolled (For example, reimbursement is not available for the summer term if I was not enrolled for summer.) I understand
I understand that the expenses must be submitted within the academic term (fall, winter, spring) that the expense actually occurred.

I understand that the expenses must be submitted within the academic term (fall, winter, spring) that the expense actually occurred. I understand
If you were referred to our office by someone, please indicate their role:

If you were referred to our office by someone, please indicate their role: University Faculty University Staff Other (please expand below)
Name of person who referred you and any other additional pertinent information regarding the referral:
Please indicate type of expense:

Please indicate type of expense: Copayments Prescriptions or medication

*Please Note* We WILL reimburse you for your copayments, but it may be a portion of the expense. If these are ongoing, it is simpler to hold your receipts and seek reimbursement for a group of these at one time. Please submit a new form for each new group of these copaypayments.
Is this a recurring expense?

Is this a recurring expense? Yes No

For recurring co-pays, please submit receipts once you have made the payment(s). If these are recurring, it is helpful to submit these in in groups rather than individually.
I am requesting this amount in Aid for these expenses. If you are unsure of the amount, please wait and complete this form when the expense is known. If you have questions in the meantime, please contact the office. $ Dollars . Cents
To provide funding, we must know an amount.
Please note that your expense may be reviewed by the University's Patient Advocacy Coordinator to determine if costs can be reduced with the care provider. Upon completion of that review, the expense will then be reviewed by the financial aid office.

Please note that your expense may be reviewed by the University's Patient Advocacy Coordinator to determine if costs can be reduced with the care provider. Upon completion of that review, the expense will then be reviewed by the financial aid office. I understand
Please describe the nature of your request and upload documentation of the expense below.
Please upload documentation from your medical provider or insurance of your expense(s). If this is a recurring expense, we ask that you save and submit receipts in batches. Help for these expenses cannot be provided without documentation.

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HEIC files are not compatible with this form.
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