Apply for Funding

Medical Funding Applicants can complete this free online application for cash funding to cover healthcare costs incurred due to a personal injury.

Please fill out the below information to the best of your knowledge. The more information provided, the easier it will be to evaluate your application for healthcare funding approval.

Funding Application

Funding Application

Personal Information

(required)
(required)
(required)

Case Information

Attorney Information

Authorization

I authorize Georgia Medical Assurance Funding to contact the attorney listed above in order to gather further non-privileged information for purposes of completing my funding request.
(required)
(required)
Sending