Application for Assistance

Patient Name *
Patient Name
Date of Birth *
Date of Birth
Diagnosis Date *
Diagnosis Date
Address *
Address
Parent #1 Name *
Parent #1 Name
Parent #2 Name
Parent #2 Name
Phone *
Phone
Alternative Phone *
Alternative Phone
Do you have health insurance *
Have you been approved for any of the following? *
Date approved for Medicaid (if applicable)
Date approved for Medicaid (if applicable)
$
Date approved for Food Stamps (if applicable)
Date approved for Food Stamps (if applicable)
$
Date approved for SSI (if applicable)
Date approved for SSI (if applicable)
$
I certify that to the best of my knowledge the information I have provided is complete and accurate. I understand that the information I have given is subject to verification by Chasin a Dream Foundation. I also understand that I am responsible to inform Chasin a Dream Foundation of any change in status. I grant permission to Chasin a Dream Foundation to use/ release my information submitted, and disclose and request on my behalf to other agencies, providers, doctors, and medical facilities for the purpose of case management, assistance and advocacy and understand that I can revoke this permission at any time in writing. Information may be shared verbally or by computer data transfer, mail or hand delivery. I further understand that Chasin a Dream Foundation is a privately funded organization and the final determination of granting of financial assistance is based on the availability of funds and the governance of its board of Directors. I also grant Chasin a Dream full photo/media privileges of my child. *
Your Name *
Your Name
Date *
Date