Resource Assistance Application

Resource Assistance Application
This is an application for all individuals seeking resource assistance from Heartspring. Assistance is available for all Heartspring programs. All information is regarded as confidential and viewed only by those involved in the approval of assistance agreements. Determination of eligibility for assistance is based solely on eligibility requirements listed in the policy without regard to race, sex, ethnicity, or religious affiliation. If applicable, assistance is provided after insurance has processed claims.

Funding is limited and Heartspring reserves the right to alter or suspend granted assistance agreements should the fiscal need arise. Resource assistance is not guaranteed and must be applied for per instance. Coverage is capped at $5,000 per child, per fiscal year.

Eligible Product and Services
The product or service identified in this application must be deemed necessary for participation in Heartspring programs by an authorized Heartspring employee.

Instructions
Complete form in its entirety and submit required documentation within 15 days of each other. If required documents are outstanding after 15 days of the initial application, the application will be denied or returned for needed information.
Child's Information
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Information
Parent/Guardian 1 Name*

First NameLast Name
Address (If different than provided above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer*
Parent/Guardian 2 Information
Add Parent/Guardian 2

Yes
Parent/Guardian 2 Name*

First NameLast Name
Address (If different than provided above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer*
Request Type
All Programs*

Communication devicesDurable medical equipmentHearing aids/Assisted listening devicesOral care (preventative, early intervention, or medically necessary)NA
Residential/Day School Only*

Emergency clothingEmergency medical careLab workMedicationParent travel supportSpecialist appointmentsSupplemental shakesTherapy servicesNA
Description of Requested Assistance*
Referred/Recommended By (Heartspring Employee)*
Provider Information
Name/Office*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Documentation*
Upload Documentation

Cancelof
Submitted By
Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Signature*

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Resource Assistance Application

Child's Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Request Type

Provider Information

Submitted By