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.

 

As shown on legal ID

 

As shown on legal ID

 
 
mm/dd/yyyy
 
 
 
 
 
 
Phone
 
Phone
 
 

 

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

 
 
mm/dd/yyyy
 

 
 

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.

 

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

 
 

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.

Drop your files here
 

 

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.


 

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.

 

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