Funding Request

REQUEST FOR FINANCIAL ASSISTANCE
Hospice Charitable Fund of Central Arizona, Inc.

Hospice Care Providers can use this form to request funding for patients.

Date of Request *Please fill the required field.

Patient First Name *Please fill the required field.

Patient Last Name *Please fill the required field.

Patient Phone *Please fill the required field.

Patient Address *Please fill the required field.

Diagnosis/Condition of Person in Need *Please fill the required field.

Describe the Need *Please fill the required field.

Amount Requested *Please fill the required field.

Describe previous efforts made for financing this need (insurance denial? requests from family members? Savings accounts? *Please fill the required field.

Provider First Name *Please fill the required field.

Provider Last Name *Please fill the required field.

Provider Phone *Please fill the required field.

HIPAA Privacy Authorization Form for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) I authorize the board members of the Hospice Fund of Central Arizona to use and disclose the protected health information described above to all board members the release of my health records as indicated above. This medical information may be used by the persons I authorize to receive this information for reviewing my application for financial assistance from the Hospice Charitable Fund. This authorization be in force and effect until six (6) months from this date at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by Federal or State law. I have read HIPAA Statement

Agree

Do Not Agree

Hospice Charitable Fund of Central Arizona

P.O. Box 11859

Casa Grande, AZ 85130-1859

Hospice Charitable Fund of Central Arizona

P.O. Box 11859

Casa Grande, AZ 85130-1859

info@azhospicefund.org

Email us

REQUEST FOR FINANCIAL ASSISTANCEHospice Charitable Fund of Central Arizona, Inc.

info@azhospicefund.org

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REQUEST FOR FINANCIAL ASSISTANCE
Hospice Charitable Fund of Central Arizona, Inc.