Heartbeat Humanitarian Application

(Tanner Employees ONLY)

To be eligible for Heartbeat Humanitarian assistance, you must be a current Tanner Health employee.

Applicant’s need for financial assistance is UNEXPECTED AND IMMEDIATE. Example: Extended Illness, Death, Fire, Accidents.


2.Applicant has no other source of sufficient funds available to meet the unexpected need. Example: No insurance reimbursement is forthcoming. No savings, other charitable funding sources, governmental assistance, or ability to secure a loan.


3.The financial crisis must be beyond the control of the applicant. Problems that arise because of a lapse of personal responsibility do not qualify for assistance. Additional information may be required by the committee to evaluate the application.


4.Employee has been employed by Tanner Health System for at least one full calendar year.


5.Monthly income must not exceed monthly expenses, unless due to extenuating circumstance approved by committee.


6.Applicant grants permission to the Heartbeat Humanitarian Committee to request and review any information of a confidential nature, including but not limited to, medical records, insurance information, financial records, payroll information, etc. that may assist the committee in their evaluation.


7.Applicant understands that, if necessary, their supervisor may be contacted to verify information pertinent to job function, work history, on the job conduct, and other information the committee deems appropriate in their evaluation.

By signing below, I certify that you agree to all above criteria. I understand that this information will remain confidential for Heartbeat Humanitarian Committee Members to review, and some information may be shared with others who the committee deems as appropriate in assisting them in the decision-making process. I also understand that my completed application will be kept in a permanent file for historical documentation and may be referenced in the future. I understand and approve the use of printing and emailing my application so committee members may review my request. I release all parties that may be involved from any liability that may arise, whether civil or criminal in nature.

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A dependent is a person who relies on another as a primary source of income.


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(Ex. support from relatives, church, social services, etc.)

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Financial Assessment



Monthly Income

Social Security/SSI, pensions/retirement pay, ADC/child support, worker’s comp, government/other assistance, savings.


Monthly Expenses

Please provide details for any additional monthly expenses.

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I have read this report and found it to have true and complete information. I have not falsified any of the information in this application or misrepresented myself, my financial declaration, or any other information. The Heartbeat Humanitarian Committee has my permission to verify all information in a confidential manner. If the information herein is found to be false, I understand this application will be denied and I may lose the right to ever request assistance from the Heartbeat Humanitarian Committee, regardless of the situation or emergency. By signing below, I release all information in this form and give consent to the Heartbeat Humanitarian Committee to access any and all confidential information that may be needed in their decision making process. I also understand I will lose my right of confidentiality for certain information that may be needed by the committee members.

Please upload any monthly bills, medical bills, or other supporting documentation for review.

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