Funding Application

Funding Application

Applications will only be reviewed if they are submitted for an unmet funding need. The applicant must have applied for and been denied or considered ineligible for assistance from programs such as Medicare, Medicaid, Denali KidCare, private insurance, or other similar programs.

If you are applying for travel assistance for a family member or escort, please enter the information for the person that would be traveling in the second (Applicant) section. Also please select "applying for someone else" and enter the escort or family member's information as the applicant.

Patient/ Recipient First Name*

As shown on legal ID

Patient/ Recipient Last Name*

As shown on legal ID

Patient Date of Birth

In which community does the patient/ recipient currently reside (please type if not listed):

Select or enter value

Please note that for an patient/ recipient to qualify for funding they must be a current resident of a qualifying community in Southeast Alaska, excluding Yakutat, Ketchikan, and Metlakatla.

Mailing Address

Mailing Address Line 2

City*

Postal/ Zip Code*

Primary Phone Number*

Phone

Secondary Phone Number

Phone

E-mail Address*

Applying for someone else?

Please check if the funding is for someone else or if this a travel request for a medical escort for the patient:

Applicant/ Escort Relationship to Patient/ Recipient

Applicant/ Escort Full Legal Name

Applicant/ Escort Primary Phone Number

Phone

Applicant/ Escort E-mail

Applicant/ Escort Date of Birth

Type of Request*

Select

All DME’s are capped at 80%, application should include invoice from provider with total cost, please upload file or image below.

Hearing Aids, Dentures, Orthodontics, Crowns/ Partials, and all other Durable Medical Equipment (DME) are capped at a maximum of $600 per year. Patient will be responsible for paying 20% of total cost before funding can be issued. Please include receipt or invoice showing total cost and amount patient paid as a file upload.

Please provide the portion of total funding that the patient is responsible for in the Patient Responsibility field, 20% of total cost up to $750. If total cost is over $750, the patient responsibility will be: (Total Cost - $750) + $150.

All DME’s are capped at 80%, application should include invoice from provider with total cost, please upload file or image below.

Eyeglasses are capped at a maximum of $250 once every 2 years. Patient will be responsible for paying 20% of total cost before funding can be issued. Please include receipt or invoice showing total cost and amount patient paid as a file upload.

Please provide the portion of total funding that the patient is responsible for in the Patient Responsibility field, 20% of total cost up to $250. If total cost is over $250, the patient responsibility will be: (Total Cost - $250) + $50.

Travel is approved once a year per patient only; whether this is one way or round trip. Travel that falls outside the SEARHC travel policy related to medical treatment will be considered only under extenuating circumstances.

Travel requests must be submitted by 12:00 pm, noon, at least one business day prior to the date of travel.

Healing Hand staff will need to speak with the patient or applicant prior to reviewing the application to confirm travel details. Please ensure you are available to speak by phone after submitting this application.

For pharmaceuticals and supplements approval may be granted for 1-3 months basis for non-formulary prescriptions or supplements recommended by a medical provider. Medical provider to give guidance on length of time for prescription coverage or supplement need. Please include documentation from provider as a file upload.

Total Funding Need

Please provide to the total cost of the goods or services needed.

Patient Funding Responsibility

Please provide the amount the patient will need to pay before funding can be issued.

Round-Trip Travel

Yes

Travelling From

Traveling To/ Location of Appt.

Date of Appt.

Travel Accomodations

Please include any requested accommodations for travel (ferry or jet travel). We will do our best to accommodate your request but cannot guarantee your preferred flights or method of travel.

Reason for Assistance*

Please let us know why the funding is needed. Include any background information to justify your request.

File Upload

Be sure to attach invoice and/or treatment plan, showing total cost and any amount paid to date, with your application for DME or pharmaceutical requests.

Drag and drop files here or

CERTIFICATION AUTHORITY & RELEASE OF INFORMATION*

By checking this box, you certify the accuracy of this application and authorize the appropriate SEARHC staff access to any information, including medical statements and/or medical records. This process is completed in order to verify the information provided on this application. All information will be kept confidential.

You understand that applications will not automatically be paid; applications must be approved and any patient obligation met before payments will be made.

You are attesting that, for this unmet funding need, you have applied for and been denied or deemed ineligible for all of the following: Medicare, Medicaid, Denali KidCare, HRSA Sliding Fee Scale, Veterans Administration benefits (VA), Vocational Rehabilitation, Tribal Assistance Programs, or private insurance.

You understand that funds can only be used for the specific purpose they are being provided for.

Please check the box below to show that you have reviewed, understand, and agree to the Certification Authority & Release of Information as stated above.

Permission to be Contacted

Please check the following box if you are willing to have the Healing Hand Foundation (HHF) contact you about your experience of applying for/receiving funds from this award. SEARHC may release only your name, address, and phone number to HHF so they may contact you directly.

Note: This information is helpful in fundraising in order to assist as may people as possible. If preferred, you can call HHF at (907) 966-8422.

Yes

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.