SCP Health Relief Fund Application

The SCP Health Relief Fund is designed to provide immediate financial assistance to active SCP Health corporate employees, employed clinicians and independent contractor clinicians who experience financial hardships resulting from unanticipated and unavoidable emergency situations.

Eligibility Requirements:

Applicant must be an active, full-time corporate employee, full time employed clinician or full time independent contractor clinician for SCP.
Eligible applicant can apply for a personal situation or one involving a spouse or legal dependent*
Must be employed or contracted by SCP for at least 90 days prior to applying
Must apply within 60 days of the incident
Employee/Clinician is limited to one grant per category per year (3 grants maximum)
Legal dependents are limited to one grant per year

* Employees or clinicians can apply for grant assistance for situations involving legal dependents. We will consider legal dependents as they are defined by the IRS - persons other than the taxpayer or spouse who entitles the taxpayer to claim a dependency exemption (ex: a child or stepchild claimed as a dependent on your tax return)

* SCP Health follows guidance provided by the IRS, which does not allow income replacement payments, such as payments of lost wages, lost business income, or unemployment compensation

Qualifying Situations/Categories:

1. Natural Disaster: events officially declared by Federal, State or Parish governments including wildfires, floods, tornados, hurricanes, severe storms or earthquakes that damage or destroy the applicant's primary residence.

2. Medical Hardship: for the applicant, spouse or eligible dependent(s). The Fund is not a substitute for medical insurance but will help meet deductibles or cover travel expenses. For medical emergencies, doctor confirmation or medical documentation will be required.

3. Material Related Hardship/Death Incident: includes non-declared, individually experienced situations such as house fires and other major material damaging events. Also includes death of the employee/clinical contractor, spouse or eligible dependent(s). Includes death care or funeral costs that prevent an applicant or their family from affording basic living expenses. Also, the fund may help to pay for relocating a child whose parent(s) have died.

Please note:

All applications will be subject to a confidential and objective review and will be approved or denied by a committee of Community Foundation of Acadiana on behalf of SCP Health
Proper documentation will be required for grant assistance and will be requested if not provided
The amount granted to an applicant can never exceed the available fund balance at the time of the application

A red asterisk (*) indicates a required field.

Select a Choice: *

SCP Employee / Clinician Name: *

First Name Last Name

Date of Birth *

Last 4 digits of Social Security Number: *

Phone Number: *

E-mail: *

example@example.com

Mailing Address: *

Street Address

Street Address Line 2

City State

Zip Code

I work for SCP Health as a(n): *

Corporate Employee Employed Clinician Independent Contractor Clinician

I am applying for a situation involving: *

Myself (the SCP corporate employee or clinician) My spouse or legal dependent*

Have you been employed or contracted by SCP Health for at least 90 days? *

Yes No

You MUST be employed or contracted for at least 90 days to be considered for assistance from the SCP Health Relief Fund. Any employee/clinician who has not met this threshold will not be eligible.

Were you an active SCP Health employee/clinician at the time of the incident? *

Yes No

You MUST be an active employee or clinician for SCP Health at the time of the applied-for incident to be considered for assistance from the SCP Health Relief Fund.

Which qualifying situation caused the financial hardship? (Hover over text to see definitions of the options below or review the descriptions at the top of the application to choose the option that best fits your circumstances) *

Natural Disaster Medical Hardship Material Related Hardship / Death Incident

Type of incident (ex: tornado, fire, type of injury, name of illness, etc.) *

Date of incident (must be subsequent to 1/23/18 and within 60 days of incident): *

Date

Of the scenarios below, please select all that applied to you personally as a result of this disaster: *

Lost Power Evacuated Primary Residence Home Damage Vehicle Damage None of the Above Other

Describe your financial hardship and your immediate needs: *

Estimated dollar amount of immediate relief needed: *

Total household income level (should include spouse, partner, etc.): *

Do you own or rent your primary residence? *

Own Rent Neither

What is your monthly mortgage or rental payment for your primary residence? *

What is your monthly car payment(s)? *

What are you other monthly expenses? *

Number of legal dependents at time of incident: *

Please estimate your out of pocket expenses incurred or to be incurred from damages, losses and expenditures detailed in the application that are NOT expected to be covered by insurance, government assistance, FEMA, or from other sources. Please exclude the costs associated with nonessential, luxury or decorative items and services: *

Are you requesting additional relief from other sources? (Ex: payments for medical or counseling services, temporary housing, etc.) *

Yes No

Can we share your story anonymously to help us build this program? (Your identity will not be disclosed) *

Yes No

Please upload up to 6 documents/pictures substantiating your situation. These could include photo evidence of home damages, insurance documents/deductibles, repair estimates/invoices, death certificates, medical bills, proof of home ownership, etc.

**If this information is not provided initially, it will be requested and could delay or inhibit the grant distribution process**

Upload up to 6 pictures / files: *

I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process. *

Yes No

Personal Information

Financial Information

Attach Supporting Documentation