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Individual and/or Family Financial Assistance Application
Person submitting this application for Individual/Family Financial Assistance?
Name
*
First
Last
Relationship to Patient
*
Phone
*
Is this a request for Bereavement Care?
*
No
Yes
Patient Information
Patient Name
*
First
Last
Phone #
*
Email
Mailing Address
*
Street Address
Address Line 2
City
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State
ZIP Code
Has the applicant/family received prior assistance from HCF?
*
Yes
No
If yes, when/amount:
*
Is the applicant/patient within the last six (6) to twelve (12) months of life?
*
Yes
No
Patient is Deceased
Financially Responsible Person’s Name
*
First
Last
Mailing Address of Person Financially Responsible
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number of Person Financially Responsible
*
Email of Person Financially Responsible
*
Requested Amount of Assistance
*
Type of Assistance Request
*
Financial Assistance
Payment of Bills
Bereavement Care
Is this an Urgent Request?
*
Yes
No
NOTE: Emergency assistance is defined as assistance that requires immediate review. In most cases, emergency assistance is related to a patient who is
actively dying
, where travel arrangements or items significantly affecting the patient’s quality of life are needed immediately.
Hospice/Palliative Care Provider Information
Hospice/Palliative Care Contact Name
*
First
Last
Hospice/Palliative Care Organization/Provider
*
Phone #
*
Email
*
Resource Investigation
Has a reasonable investigation into other sources of funding been conducted?
*
Yes
No
List of the agencies/resources that have been investigated and other sources of funding:
*
Agency/Resource
Funding Provided
Use + at end of row to add additional rows as needed.
Assistance Request
Detailed Assistance Request
*
Explain the patient and/or family circumstances which are causing a financial need for the applicant.
How are the circumstances causing financial distress directly related to the patient’s terminal diagnosis?
*
Any additional comments or information which may be helpful for the Assistance Review Committee to consider when making a decision regarding this request?
Assistance Application Worksheet
*
Accepted file types: doc, docx, pdf.
Please upload the completed Assistance Application Worksheet
here
.
Requested Assistance
*
Bill/Expense
Amount Due
Amount Requested
Use + at end of row to add additional rows as needed.
Signature
Please Note: Financial Assistance is limited to $500.00 per request with a lifetime limit of $1,000.00. Assistance will most often be paid directly to the vendor. In case of gas, groceries, personal use items, etc., HCF may choose to purchase a gift card to be presented directly to the applicant.
By signing below and submitting this form I certify that the information presented is true and accurate to be best of my knowledge and that it includes all income and expenses for the applicant’s household; that the applicant, family and/or hospice agency has attempted to seek other resources to help assist the applicant and that upon request, verification of expenses will be provided.
Signature of Applicant
*
First
Last
Signature of Power of Attorney/Hospice Provider (if applicable)
First
Last
Applicant's Email
*
For confirmation.
Questions may be directed to Kevi Berger at 406-541-2255 or kevi@hcfmissoula.com.