Student Athlete Grant Request

Program Statement

TRA Medical Imaging (TRA) and the Tacoma-Pierce Athletic Commission (TAC) have partnered to launch a special community program that provides free or reduced‑cost diagnostic imaging services to local student‑athletes who demonstrate financial need. We believe that fear of paying for an injury should never be a barrier to participating in youth athletics in our community. This collaboration is designed to ensure that student athletes receive timely, medically necessary imaging to support their health, injury evaluation, recovery, and safe return to play.

ATHLETE INFORMATION

Athlete Name:

Date of Birth:

Email:

Phone Number:

Address:

GUARANTOR/PARENT INFORMATION

Guarantor/Parent Name:

Email:

Phone Number:

Address:

REFERRING PROVIDER INFORMATION

Ordering Provider Name:

Clinic/Practice:

Provider Phone Number:

NOTE: A valid imaging order must be provided before scheduling.

FINANCIAL ASSISTANCE REQUEST

TRA’s Student Athlete Financial Assistance Program provides imaging at reduced or no cost for approved applicants. No cash awards are issued. This program is intended for patients who otherwise face a financial barrier to receiving medically necessary imaging.

Please describe what financial barrier prevents you from obtaining imaging:

UninsuredUnderinsured/ High-deductible planMedicaid pendingOther

YesNo

Supporting Documentation

Please attach (if available):

Imaging order from your referring provider (required prior to scheduling)
Recent bill, denial letter, or cost estimate (if applicable)
Any additional information supporting financial hardship
A copy of the current letter of determination from another health care organization that has granted you financial aid (if applicable)
Source of income (wages, child support, pension, etc.) for the patient and/or other family in the home.

File Upload

Total household income:

Please list the name, relationship, and age for all dependents in your household, including the student athlete:

ACKNOWLEDGMENT & CERTIFICATION

By signing below, I certify that the information provided is true and complete. I understand that:

This grant provides imaging services only at TRA Medical Imaging.
Approval is not guaranteed.
Additional documentation may be required.
All imaging must be medically necessary and supported by a valid provider order.

Signature

Date: