Name of Physician (required)
Name of authorized person (from Physician Sign Up Form) submitting request (required)
Email of authorized person (from Physician Sign Up Form) submitting request (required)
Date of Request (required)
Do not use patient name or identifying information
Zip Code (required)
Diagnosis of patient being treated (required)
Ethnicity of patient
---White/CaucasianBlack/African-AmericanHispanic/LatinoAsian/Pacific IslanderNative American/IndianOther
---0 - $15,000$15,001 - $25,000$25,001 - $35,000$35,001 - $45,000$45,001 - $60,000Over $60,001Unknown
If request is not granted (required)
---Patient would be unable to receive needed service/itemPatient would receive service at great financial hardshipOther
If "Other" please fill in blank
Do any of the following describe the household for which assistance is being requested?
---UnemployedSingle parent householdAll of the aboveNone of the above
Explanation of Request
Vendor/Company providing service requested
If Foundation's maximum $500 grant will not cover full cost, please explain plan to fund the remainder.
Description of request. Please include specific information about the nature of the request, cost, vendor, and description of reason for request. Please describe the family circumstances & medical condition necessitating this request.
If you have any questions you may email Sharla McGinnis at email@example.com