Medical Needs Assistance Application

Medical Needs Assistance Application

Assistance requests of up to $2500 will be reviewed bi-monthly. Only complete applications can be considered. Please contact Leonela Gonzalez, CMN Hospitals Program Coordinator, with any questions at lgonzalez5@SalinasValleyHealth.com or 831-759-3017.
Today's Date*

MonthDayYear
Date
Child's Full Name*

First NameLast Name
Child's Birthdate*

MonthDayYear
Child's Current Age*
Child's Gender Identity*

MaleFemaleNon-BinaryOther
Name of Parent / Guardian / CASA*

First NameLast Name
Parent / Guardian / CASA's Phone Number*
Parent / Guardian / CASA's email*
Child's Residential Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing / Shipping Address (if different than residential address)

Street Address

Street Address Line 2

CityState

Zip Code
Child's Diagnosis / Medical Condition(s):*
How did you learn about the Medical Needs Assistance Program?*
Additional family members living in household (please provide name, relationship, and age for each)*
Referring doctor / clinical care provider (please provide name and phone number)*
This should be the name and phone number of the care provider that provides your statement of medical need or medical benefit.
Upload a letter from a clinical care provider (on professional letterhead) indicating the medical BENEFIT of the requested item or service. Please note this does not need to be medically "necessary" but does need to be medically "beneficial." *

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Type of Need*

EquipmentInpatientOutpatient (including therapy)Other
Have you previously received a CMN Hospitals Medical Needs Grant?*

YesNo
If yes, what year?
Amount of funding requested*
This is the total cost of the item or service(s) that you are requesting funding for.
What item or service are you requesting funding for? *
Upload a quote from the applicable provider or vendor for the requested item or service*

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Total gross monthly household income (include all sources including wages, Social Security, State / Federal Assistance, etc. for all working adults living in the household)*
Potential Pay Source(s)*

Private InsuranceMedi-CalCCSNoneOther
Upload the summary sheet from your prior year's tax return showing your total household income (social security numbers may be redacted)*

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I approve the release of applicable medical records for the above named child in order for the Salinas Valley Health Foundation to consider this application:*
This allow us to speak with your child's care provider for additional information if needed
I am willing to share my child's story and/or photo in order to help future fundraising efforts for my local Children's Miracle Network Hospitals Program. The Medical Needs Assistance Program is funded completing by donations (If yes, a CMNH representative will contact you for additional information).*
*This does not affect funding decision
Are you affiliated with a Children's Miracle Network Hospitals Partner (employee, related to an employee, referred to us by the partner, etc.)?*
If yes, please select the applicable partner:

CostcoPanda ExpressWalmartRite AidWalgreensBay Federal Credit UnionChevronSpeedwayDairy QueenMarriottAce HardwareGreat ClipsRE/MAX7-ElevenOutdoor Supply HardwareCorFed Credit UnionOther
Signature of Parent / Guardian / CASA*

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