Hospice Care Foundation | 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?*

Patient Information

Patient Name*

First Last

Phone #*

Email

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Has the applicant/family received prior assistance from HCF?*

If yes, when/amount:*

Is the applicant/patient within the last six (6) to twelve (12) months of life?*

Financially Responsible Person’s Name*

First Last

Mailing Address of Person Financially Responsible*

Street Address Address Line 2 City State ZIP Code

Phone Number of Person Financially Responsible*

Email of Person Financially Responsible*

Requested Amount of Assistance*

Type of Assistance Request*

Is this an Urgent Request?*

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?*

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*

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.

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Individual and/or Family Financial Assistance Application

Person submitting this application for Individual/Family Financial Assistance?

Patient Information

Hospice/Palliative Care Provider Information

Resource Investigation

Assistance Request

Signature

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