Keystone Care Foundation - Hart Fund Scholarship Application

Hart Scholarship Fund

Application for Financial Assistance
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How many people reside in your household (including yourself)?*
How did you first hear about the Hart Scholarship Fund?*
Should you receive financial assistance, would you be willing to provide a testimonial of your care?*

YesNo

Please list current and ongoing problems, in addition to your main health concern/diagnosis, in order of priority:*

	Describe Problem	Severity (Mild/Moderate/Severe)	Prior Treatment/Approach	Effectiveness (Excellent/Good/Fair)
1
2
3
4
5
6

Please list your current Medications and Supplements (includingVitamins, Minerals, Herbs and Homeopathic Remedies).*

Have you made any changes in your eating habits because of your health?*

YesNo
If your answer to the above question was YES, please describe and include information about any special diet or nutritional program you may follow. If your answer to the above question was NO, please enter N/A in the space provided.*
Describe your mental and emotional health. Please include any relevant treatment and/or practices that contribute to your mental and emotional wellness, including but not limited to therapy, meditation, attending church,and mind/body/spirit therapies.(Optional)
Are you currently or have you recently experienced a significant life event?Ifyes, please include any life events that feel significant to you, including but not limited to changes in your relationship, family, work, financial status, dietary or stress levels.(Optional)
What do you hope to gain by receiving alternative medicine treatment?**

Current Treatment*

	Full Name (With Medical Title)	Role (Chiropractor, Health Coach, etc.)	Contact Information	How Long Have You Been Receiving Treatment?
1
2
3
4

Past Treatment*

	Full Name (With Medical Title)	Contact Information	How Long Did You Receive Treatment?	Why Did You Stop?
1
2
3
4

Please upload a letter written by your practitioner(s) for which you are applying for financial assistance, detailing your treatment plan and approximate cost. Applicants must currently be an accepted patient of the practitioner/center for which you are applying for financial aid. All monetary aid provided by the Hart Scholarship Fund shall be paid directly to the practitioner/center. Without this letter, your application is incomplete and will not be considered.*

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Financial Information*

Name of Health Insurance*
Please describe your employment. (Include your occupation, the number of hours per week you work, your salary or hourly wage, and how long you have worked there.) Students please note the name of your school (or if you are home-schooled), what your grade/year is, and whether you are enrolled full time, part time or are on any type of leave of absence.*
If you do not have monthly income, please explain how you take care of your monthly expenses. Use additional pages if necessary.*
Please use this space to tell us anything else that you feel we should know.

I, blanks* (name), hereby authorize the use or disclosure of my individually
identifiable health information (“Protected Health Information”) by the Keystone Cares Foundation, (Hart Scholarship Fund) a non-profit organization, to make determinations for financial assistance and need. I understand that my Protected Health Information may be subject to re-disclosure by The Keystone Cares Foundation pursuant to this authorization. I understand that The Keystone Cares Foundation, Inc. will not use my Protected Health Information for any reason other than that which is stated above without my further authorization. I understand that I may revoke this authorization at any time by notifying the The Keystone Cares Foundation in writing, but if I do, it will not have an effect on any actions The Keystone Cares Foundation took before it received the revocation of this authorization.
Signature*

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Date:*
Date of Birth:*

MonthDayYear
Date
Name of Individual's Representative (if applicable):

First NameLast Name
Relationship to the Individual (if applicable):
By checking this box, I agree to keep confidential the amount that may be awarded to me as part of this scholarship program.
By checking this box, The Keystone Cares Foundation can follow up with me at periodic intervals to access private health care information, if necessary.

SIGNATURE PAGE TO APPLICATION
I hereby certify that all information and attachments are true to my knowledge. I understand that
false information may disqualify me from consideration for this award.
Dated:*
Signature*

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Financial documentation (most recently submitted tax return or tax transcript from the IRS)*

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Checklist for completed Hart Scholarship Fund Financial Assistance Request Form:*

Application CompletedFinancial documentation (most recently submitted tax return or tax transcript from the IRS)Completed release of information
Should be Empty:

Hart Scholarship Fund