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  • PharmHP Assistance Fund Application

  • Purpose: The PharmHP Assistance Fund is created to provide financial assistance for participants enrolled in the Pennsylvania Pharmacists’ Health Program who have demonstrated financial assistance need for fees associated with: case initiation, monitoring, advocacy, testifying, drug testing, treatment, and evaluation.

    PharmHP Assistance Funds cannot be utilized to pay for evaluation or treatment services associated with non-profit providers who have the ability to fundraise through their 501-c-3 IRS designation.

    Eligibility: PharmHP participants wishing to apply for assistance must meet the following criteria:

    1. Participants must be enrolled in the PharmHP Program.
    2. Participants must have a demonstrated financial need.
    3. Participants must complete an online PharmHP Assistance Fund application and provide the required collateral materials. Incomplete applications will not be accepted.

    Guidelines:

    1. Please note that the penalty for submission of fraudulent information will be immediate cessation of financial assistance.
    2. Assistance is provided for a limited time.  If additional assistance is needed, another application will need to be completed.
    3. Applications will be reviewed and approved by the Sr, Director of Finance and Operations and PharmHP Staff.
    4. Required Supporting Documents include:
      • Federal tax information or tax returns including IRS W-2 information, for you (and your spouse, if you are married), and for your parents if you are a dependent student
      • Records of your untaxed income, such as child support received, interest income, and veterans noneducation benefits, for you, and for your parents if you are a dependent student.
      • Information on cash; savings and checking account balances; investments, including stocks and bonds and real estate (but not including the home in which you live) for your parents if you are a dependent student
    5. Questions regarding the fund or application process may be directed to the PharmHP at (717) 558-7819, Monday through Thursday, from 8:00 a.m. to 4:00 p.m.
  • Section 1: Applicant Information

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  • Section 2: Income

  • Section 3: Monthly Expenses

  • Personal

  • Insurance Premiums

  • Taxes

  • Section 4: Assets

    List market value of all assets owned, including those on which you have outstanding loan balances (for example real estate, home mortgage, vehicles, auto loans):
  • Section 5: Liabilities

    List outstanding balance of all liabilities:  
  • Section 6: Attestation

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