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Financial Assistance Program & Application

After careful review, your healthcare provider determined that genetic testing by Baylor Miraca Genetics Laboratories is necessary. Baylor Miraca Genetics Laboratories abides by the contractual and legal obligations of health benefit plans to collect charges, co-pay, co-insurance, and deductible amounts owed by patients. Baylor Miraca recognizes that circumstances may arise where an individual is unable to pay. We adopted a process of screening requests for delayed payment plans, discounts, or forgiveness of debt based on individual circumstances. This financial assistance program is our commitment to work with patients and assure that necessary genetic testing can be provided at a reasonable cost for those with a financial need or for those who are under insured. Baylor Miraca will calculate your financial need based on your annual adjusted gross income and the number of family members in your household.

If you meet of the following criteria, please complete the information and print your name at the attestation below.
  • Patient has healthcare insurance and is experiencing financial hardship.

    • Copy of Most Recent IRS 1040 Tax Form
    • Earnings From Work - Last 2 Paycheck Stubs
    • Unemployment Payment Information
    • Social Security Disability or Survivor Benefits
    • Child Support Statement
    • Proof of Bankruptcy Settlement
    • Catastrophic Situation (Death or Disability)
    • Other Documentation Showing Inability to Pay

    You may also fill out the PDF version of this form and email to