Medical Assistance Request Form
Request assistance from Angel's Hands Foundation for medical necessities. Please understand that no request for personal assistance will be considered unless the family has been registered with AHF for at least one year.
Parent/Guardian Name (1)
*
First Name
Last Name
Parent/Guardian Name (2)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Child's Name
*
First Name
Last Name
Child's Birthdate
*
-
Month
-
Day
Year
Date
Are you the parent or guardian of a child with a rare disease?
*
Yes
No
What is the diagnosis?
*
What type of assistance are you seeking from AHF?
*
Estimate of medical equipment cost (invoice or order form), must be attached or emailed within 30 days of request.
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Letter of Medical Necessity must be attached or emailed within 30 days of request.
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In order to have medical bills considered, medical statements showing insurance payments must be attached or emailed within 30 days of request.
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What type of assistance (if any) have you received from AHF in the past? This will not affect your current request, it is for data purposes.
What other agencies have you contacted to help with this request, if any?
I understand that no request for personal assistance will be considered unless my family has been registered with AHF for at least one year.
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