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 Burial/Cremation 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 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?
Requested Assistance*
Bill/Expense Amount Due Amount Requested

Use + at end of row to add additional rows as needed.
Financial Assistance Worksheet*
Accepted file types: doc, docx, pdf.
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/Hospice Provider (if applicable)
First Last
Applicant's Email*

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 Kevi Berger at 406-541-2255 or kevi@hcfmissoula.com.

Last Revision Jun 2018

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Agency/Resource	Funding Provided

Bill/Expense	Amount Due	Amount Requested