Undergraduate Copayment or Prescription Aid Request 2026-27

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 Associate 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:
I am requesting emergency assistance for one of the following (in almost all cases we will need a copy of the paid bill from your provider, please upload a copy with the link on the bottom of this form).

Please do not use this form if your expense does not fall into the categories below.

I am requesting emergency assistance for one of the following (in almost all cases we will need a copy of the paid bill from your provider, please upload a copy with the link on the bottom of this form). Please do not use this form if your expense does not fall into the categories below. Mental Health Copayments Prescription Medication
Mental health copayments are limited to a maximum of $20 per session in assistance. Itemized invoices from the provider are required; payment receipts cannot be accepted. Please note that assistance is not available for missed appointment fees.
Prescription medication must be covered by either insurance or a prescription discount card such as GoodRx. Over-the-counter (OTC) medications are not eligible for assistance.
I understand
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. If this is a large expense and you need advance funding, you will later need to provide receipts. If advance funding exceeds your eventual bill, you will be required to reimburse the university.

If you need advance funding for a large expense, please explain in the text box below.
Please describe the nature of your request and upload documentation of the expense below.
Please upload documentation of your expense(s). In the case of medical expenses, please provide documentation from your medical provider. Help for medical expenses cannot be provided without documentation.

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 in 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.

Undergraduate Copayment or Prescription Aid Request 2026-27

Undergraduate Copayment or Prescription Aid Request 2026-27

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.

Mental health copayments are limited to a maximum of $20 per session in assistance. Itemized invoices from the provider are required; payment receipts cannot be accepted. Please note that assistance is not available for missed appointment fees.

Prescription medication must be covered by either insurance or a prescription discount card such as GoodRx. Over-the-counter (OTC) medications are not eligible for assistance.