Healthcare Support Program
What health support do you require? (Check all that apply)
Medication support
Post treatment Bill Assistance
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Section A: Applicant Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Phone Number
Residential Address
District/Region
Nationality
Are you currently registered under the National Health Insurance Scheme (NHIS) or any other health insurance Policy?
Yes
No
If yes, please specify and provide policy number
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Section B: Application Information
Briefly describe the illness or medical condition
Do you currently have a medical diagnosis?
Yes
No
Have you received any treatment so far?
Yes
No
If yes, where and when?
Are you currently in need of financial support to seek medical care?
Yes
No
Have you already received treatment but are unable to pay the hospital bill?
Yes
No
Are you the patient, or are you submitting this request on behalf of someone else?
Yes
No
Are you currently on admission?
Yes
No
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Section C: Supporting Documents
A completed Doctor's support form (Please download form below and ensure it is completed by your medical doctor or healthcare provider), A copy of a valid national ID or other form of identification, A copy of your NHIS card or other Health Insurance Policy card.
Please tick where applicable and attach the following documents (if available):
Browse Files
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Section D: Emergency Contact Details
Full Name
First Name
Last Name
Your Relationship with Person
Phone Number
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How did you hear about Turning Point Foundation’s Health Support Program?
Please Select
A healthcare provider or facility
Family or friend
Community outreach or event
Website
Other (please specify)
Please Specify:
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