The Manors Foundation

The Manors Foundation

Patient Assistance Application
The Manors Foundation helps Mississippi kidney patients cover the everyday costs that get in the way of treatment. Assistance is limited to $200 per patient per calendar year, is reviewed on a case by case basis, and is paid directly to the vendor rather than to the patient.Verification is completed inside this application. There is no separate form to download or attach.
PATIENT INFORMATION
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
If the patient does not have an email address, enter the social worker's address so notices reach someone.
ASSISTANCE REQUEST
Type of Assistance Required

Other
The Manors Foundation does not pay rent or provide housing assistance at this time.
Description of Need
Describe the need in a sentence or two, including why it affects the patient's treatment or stability. If you selected Other, please be specific.
Amount Requested
Assistance is limited to $200 per patient per calendar year. If the patient has already received assistance this year, requests above the remaining balance may be partially funded.
Vendor Name
The business or provider we would pay directly.
Vendor Address

Street Address

Street Address Line 2

CityState

Zip Code
Only if it is not shown on the attached invoice.
Vendor Invoice

An invoice, bill, or statement showing the amount owed and who to pay.
Cancelof
Who is completing this form?
Patient / ApplicantSocial Worker / Medical Provider
SOCIAL WORKER/MEDICAL PROVIDER
Name

First Name Last Name
Title
Facility
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By checking each box below, I verify the following:
I certify that I am a social worker or medical provider at the facility named above, that the information in this application is true and accurate to the best of my knowledge, and that I am submitting it with the patient's permission.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

PATIENT INFORMATION

ASSISTANCE REQUEST

SOCIAL WORKER/MEDICAL PROVIDER