Hospice Care Foundation | Individual and/or Family Financial Assistance Application

Individual and/or Family Financial Assistance Application

WORKSHEET: TO BE DONE PRIOR TO ASSISTANCE APPLICATION

This worksheet is designed as a tool for the applicant to collect the required information from the individual/family who is applying for Individual and/or Family Financial Assistance. The information collected on this worksheet can then be used to submit the online grant application.

Financial Assistance Worksheet

Person submitting this application for Individual/Family Financial Assistance?
Name*
First Last
Relationship to Patient*
Phone*
Is this a request for Respite or Bereavement Care?*
Is this an Emergency Request?*
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.

Emergency requests will typically be reviewed within 48 hours.
Patient Information
Name*
First Last
Phone*
Email
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Are you/is the 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
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.
Have you/your family received prior assistance from HCF?*
Previous HCF Assistance*
Date Amount Received

Use + at end of row to add additional rows as needed.
Assistance Request
Total Amount of Assistance Requested*
Itemized Assistance Request*
Expense Item Cost or Amount Due Amount Requested

Please provide itemized breakdown of the total requested assistance. Use + at end of row to add additional rows as needed.
How are the circumstances of the patient's terminal diagnosis causing financial distress?*
Any additional comments or information which may be helpful for the Assistance Review Committee to consider when making a decision regarding this request?
Financial Assistance Worksheet*
Accepted file types: doc, docx, pdf, jpg, jpeg, png.
Please upload the completed Financial Assistance Worksheet. The Worksheet can be downloaded here.
Does the Assistance Worksheet show a monthly income that exceeds monthly expenses by $500.00 or more?*
Does the Assistance Worksheet show liquid assests of $500.00 or more?*
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 (if applicable)
First Last
Email of Individual Completing this Application*

For confirmation.
Ineligible Income Criteria
Individual and/or Family Financial Assistance can be awarded only if the applicant is considered “needy and distressed.”
- Individuals and/or families are not defined as “needy and distressed” if monthly income exceeds monthly expenses by $500.00 or more.
- Individuals and/or families are not defined as “needy and distressed” if they have $500.00 or more in liquid assets.
If you have any questions about your financial eligibility for Individual and/or Family Financial Assistance, please contact Kevi at 406-541-2255.
Questions may be directed to 406-541-2255 or grants@hcfmissoula.com.

Last Revision Jun 2019

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