Pay-it-Forward/Sunshine Fund Application
The Pay-it-Forward/Sunshine Fund assists Delaware County residents who encounter a sudden event that leaves them with an unexpected and uncovered health-related financial burden. Anyone can submit an application - the individual who experienced a sudden event, a friend, family member, or advocate. Names will be kept confidential, unless the recipient explicitly gives TCF permission to share their information.
Eligibility Requirements. Check all that apply:
*
Applicant/Nominee is a resident of Delaware County, Pennsylvania
Applicant/Nominee has experienced an unexpected event (e.g. car accident, house fire, etc)
Applicant/Nominee has un-covered medical costs (e.g. copays, medications, etc)
Name of Nominee/Applicant
*
First Name
Last Name
Address of Nominee/Applicant
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
First Name
Last Name
Contact Person's Address (If Different Than Above)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person Email
*
example@example.com
Contact Person Phone Number
*
-
Area Code
Phone Number
Best Day/Time to Reach Contact Person
*
Describe the unexpected event or accident that caused hardship
*
Describe the unfunded healthcare costs (e.g. co-pays, prescriptions, hospital parking etc)
*
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