LHW Patient Aid Request Form

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1. Type of Financial Aid Requesting?

Utility Bill Payment

Mortgage/Rent Payment

Gas Card

Grocery Card

Travel or Lodging Expense

Funeral Assistance

Medical Bill or Prescription Expense

Other (please specify):

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2. If Asking for Help Paying a Bill, Can You Send A Copy of The Bill By Email or Fax?

Yes

Not Applicable

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3. Provide brief explanation of patient situation and financial hardship:

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4. Patient Information:

Date of Request:

Requested By:

Patient Name:

Male or Female:

Patient's Age:

Address:

City:

State:

Zip:

Father's Name:

Father's Cell Phone Number:

Mother's Name:

Mother's Cell Phone Number:

Language Spoken:

Email Address for Family:

Is Mother Currently Employed:

Is Father Currently Employed:

Number of IMMEDIATE Family Members In The Home:

Is Both Parents Living in the Home with Child:

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5. Estimated Monthly Family Income and Assets:

TOTAL Monthly Family Income:

Balance in Checking:

Balance in Savings/CD/Money Market:

Amount of Family & Friends Support:

Amount of recurring In-kind Donations (room & board, gas or grocery asst):

Amount in Go-Fund Me Account:

Assistance from another Foundation or Source:

Calif Children's Service Aid or Other State Aid:

Other:

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6. Estimated Monthly Immediate Family Expenses:

Mortgage/Rent Payment:

Utilities and Phone:

Transportation (car payment, insurance, and gas):

Medical Bills:

Food:

Debt from lost income or treatment:

Other:

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7. Patient's Medical Information: (Should Be Completed By The Patient's Doctor, Nurse, or Medical Social Worker):

Diagnosis:

Date of Diagnosis:

Doctor's Name:

Hospital:

Name of Person Completing This Form:

Phone Number of Person Completing This Form:

Medical Social Workers Name:

Medical Social Workers Email:

Medical Social Workers Phone Number:

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8. Include additional explanation or comments below. Little Heart Warriors will review information & reply to person submitting request within 24-48 hrs. Funds are limited and based on availability. All information provided is strictly confidential and used to help determine aid by Little Heart Warriors. Please email support documents for bill pay request to LittleHeartWarriors@yahoo.com or fax to 909-355-3341.