Upon completion and submission of this application, I certify that:
1.The information supplied therein is true, accurate, and complete to the best of my knowledge. Pier 34 will immediately revoke any granted assistance if false information is provided in this application.
2. My protected health information could be utilized for coordination of benefits.
3. I understand that Pier 34 is a foundation that reimburses providers for mental health services, that have been rendered following approval, and our organization is not an insurance company.
If you are in need of assistance with this submission please contact Amanda at: