The Manors Foundation
Patient Assistance Application
Emergency financial support for dialysis and kidney disease patients facing hardship.All applications must include social worker verification and supporting documentation. Payments are issued directly to vendors.
PATIENT INFORMATION
Name (Required)
First Name
Last Name
Date of Birth (Required)
-
Month
-
Day
Year
Date
Address (Required)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Required)
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Required)
example@example.com
ASSISTANCE REQUEST
Type of Assistance Required
Transportation
Prescription Medication
Food Assistance
Utility Assistance
Rent / Housing
Medical Supplies
Other
Description of Need (Required)
Amount Requested (Required)
Vendor Name (Required)
Vendor Address (Required)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is completing this form?
Patient / ApplicantSocial Worker / Medical Provider
SOCIAL WORKER/MEDICAL PROVIDER
Name (Required)
First Name
Last Name
Title (Required)
Facility (Required)
Email (Required)
example@example.com
Phone Number (Required)
Please enter a valid phone number.
Format: (000) 000-0000.
Verification (Select all that apply)
Patient is receiving dialysis or kidney treatment
Patient is experiencing financial hardship
Request is medically necessary
Documentation has been reviewed
Signature (Required)
PATIENT/APPLICANT
Upload Completed Social Worker Verification Form (Required)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Vendor Invoice / Bill (Required)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I certify that the information provided is true and accurate
Signature
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Submit
Should be Empty: