Patient and Family Assistance Application

Patient and Family Assistance Application
Thank you for your interest in the Carrie Tingley Hospital Foundation Patient and Family Assistance Program. This Patient and Family Assistance Program is designed to provide temporary assistance and access to Current Carrie Tingley Hospital patients who meet the pre-defined eligibility criteria. Please complete each section of this application form as indicated below.

In order for us to process the application form, it must be complete. Each required field must have an entry. If something does not apply, please indicate N/A. Unfortunately, incomplete applications will delay the review process and final determination.

For questions please contact the Carrie Tingley Hospital Foundation at (505) 243-6626.

Qualified Applicants
- Must have been a patient at Carrie Tingley Hospital within the past 2 years.
- The patient must be under the age of 18.
- Must meet one or more of the following patient diagnosis:
  - Spina Bifida
  - Cerebral Palsy
  - Muscular Dystrophy
  - Neurological Diagnosis
  - Accidents that have caused a physical disability that affects the muscular/skeletal system.
- Funds must be used for the following:
  - Adaptive Equipment
  - Emgergency Assistance (Rent/Mortgage/Utilities/Car Repairs)
  - Vehicle Modifications
  - Home Modifications
- All applicants must have a denial from an entity on the resource page of the website before applying to Carrie Tingley Hospital Foundation.
- All emergency requests require a copy of the bill that needs to be paid.
- Adaptive equipment assistance requires a copy of your insurance company's denial letter.
- Vehicle modification assistance requires a quote with a total cost.
- Home modification assistance requires licensed/bonded contractor information and clarification of how the total project cost will be funded.
- Carrie Tingley Hospital Foundation DOES NOT reimburse families directly. All payments are made directly to the vendor.

Patient Information
Name*

First NameLast Name
Date of Birth *

DayMonthYear
Gender*
Ethnicity*
Qualifying Diagnosis
Current Address *

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry

Parent/Guardian Information
Parent/Guardian Name*
Phone Number*
Email Address*
Number of People In Your Household*
Have You Received Assistance In the Past 12 Months?*
Have You Attended Camp Adventure?*
Are You Receiving Other Services From the Foundation?*
Vendor Information
Account Holder Name*
Vendor Name*
Vendor Contact Name*
Vendor Phone Number*
Vendor Contact Email Address*
Address *

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry

Documents to be Uploaded
Medical Denial

Cancelof
Assistance Denial

Cancelof
Invoice

Cancelof
Statement

Cancelof

Acceptance of Terms & Conditions and Declaration of Parents/Guardian
Declaration by Parents/Guardian

We are seeking financial assistance for our daughter/son (hereinafter referred to as Child) after having read, understood and agreed with the terms and conditions below. We accept them and confirm that our acceptance has not been obtained by any kind of pressure or coercion of any nature whatsoever by Carrie Tingley Hospital Foundation.
1. This application has been made by us after having read and understood all qualifications.
2. We declare that the information furnished by us in this application is true to the best of our knowledge and belief.
3. We fully understand that financial assistance is based on merit and on availability by Carrie Tingley Hospital Foundation.
4. We understand the financial assistance to the child is provisional and the same may be cancelled should any of the statements made in this form is false or the relevant documents are not produced within the 7 days of filing this application unless a different timeline has been agreed upon in writing.
5. We fully understand that a denial from our insurance carrier or assistance denial from one of the entities on the resource page.
6. The Carrie Tingley Hospital Foundation reserves the right to increase/ revise/amend the assistance structure from time to time. These changes could be in line with changes in Governing Policies.
7. We understand and accept that the School has the right to use our child's photograph for any publicity material, website, social media page/s, unless the same has been expressly objected to by us and intimated in writing to the School by us before the commencement of the Academic Year.
8. We fully understand and agree that no document other than those required by the Carrie Tingley Hospital Foundation will be entertained with this application.
9. By pressing the Submit Button, we confirm the above declaration and accept the terms and conditions.
Signature

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Patient and Family Assistance Application

Patient Information

Parent/Guardian Information

Vendor Information

Documents to be Uploaded

Acceptance of Terms & Conditions and Declaration of Parents/Guardian