Medical Copayments or Prescriptions 2025-26

If you encounter financial circumstances that are above the standard cost of attendance and are receiving need-based financial aid, the University may be able to provide assistance. 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, proof of insurance coverage or proof of discount/cost reduction. Because our ability to address your emergency funding request requires you to be a currently enrolled student, please submit all requests in the term in which the expense occurs.

If you have questions, please contact the Office of Undergraduate Financial Aid at undergradaid@u.northwestern.edu. If you have specific concerns, please contact Senior Assistant Director of Financial Aid John Richmond (john.richmond@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 Northwestern Email Address
Your Phone Number Your Phone Number - ### - ### ####
Were you referred to our office for the emergency aid program?

Were you referred to our office for the emergency aid program? Yes No
Please indicate their role:

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: Mental health copayments Prescriptions or medication

We may reimburse you for your copayments, but it may be a portion of the expense. If these are ongoing, please hold your receipts and seek reimbursement for a group of these at one time.
Is this a recurring expense?

Is this a recurring expense? Yes No

For recurring co-pays, please submit statements for all appointments at one time.
Total amount of aid being requested. If you are unsure of the amount, please wait and complete this form when the total cost of the expense is known. If you have questions in the meantime, please contact us. $ Dollars . Cents
To provide funding, we must know the total amount of the request after insurance or other discounts have applied.
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). Help for these expenses cannot be provided without documentation.

Attach Files

HEIC files are not compatible with this form.
Acknowledgements

Acknowledgements 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. I understand that requests must be submitted within the academic term in which the expense actually occurred. I understand that expenses that occurred prior to the current term will not be approved. I understand that insurance coverage is a requirement to receive assistance for expenses through the emergency aid program.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. By signing this, I confirm that I am the individual completing this form and all the above information is accurate and true. Clear

Full Name

I understand this is a legal representation of my signature. By signing this, I confirm that I am the individual completing this form and all the above information is accurate and true.

Medical Copayments or Prescriptions 2025-26

Medical Copayments or Prescriptions 2025-26

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.