Living Assistance Fund Application

Living Assistance Fund Application

The Living Assistance Fund was created to provide financial aid to solid organ transplant recipients to reduce their stress during their medical procedures. We do this by paying for basic living necessities like housing, utilities, medication and transportation to the hospital. Currently, the program is open to recipients who are either Arizona residents or who were transplanted in Arizona. Applications accepted from Transplant Social Workers on behalf of their patients.
Social Worker's Name

First NameLast Name
Social Worker's Email Address
example@example.com
Social Worker's Phone Number
Format: (000) 000-0000.
Transplant Facility

Other
Transplant Recipient's Name

First NameLast Name
Transplant Recipient's Birthdate

MonthDayYear
Date
Transplant Recipient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transplant Recipient's Phone Number
Format: (000) 000-0000.
Transplant Recipient's email
By entering an email address, TCA has permission to add recipient to our email list to receive monthly newsletter.
Recipient's Total Monthly Gross Income (if currently none, enter Zero)
Recipient's Household Size
Recipient's Race

Other
Recipient's Gender Identification

Other
Has Recipient received a solid organ transplant?
Date of Transplant
Type of Transplant

Other
Transplant Center where the transplant was/will be performed if different than above:
Select one type of assistance - Pex Card for gas/grocery funds, Temporary Lodging or Other Assistance
PEX Card for Gas / Grocery Assistance - $300
Enter amount up to $300
Temporary Housing is offered as a reimbursement unless patient is rooming at Editha House or Help & Healing Home. $500 limit
Other Assistance $500 Limit - enter amount requesting
Enter amount up to $500
What help does the Recipient need?

Other
Why does the recipient need financial assistance? Please include relevant info to be able to make payment. For example - Phone number for temp lodging, plus name the reservation is under or name and contact info for pharmacy.
Does the patient have insurance?
If Yes, who is the insurance provider?
Last 4 digits of PEX Card (if applicable)
Submit a copy of the bill to be paid BEFORE requests for assistance are considered.

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By typing your name below, you agree that your patient understands that payments are made directly to the service provider, property manager or landlord and not to the patient or transplant center. This is an application for a grant of up to $500 that the patient does not pay back. Please attach copies of bills you are requesting grants. I hereby certify that the answers on this form are true and correct. I understand that a false statement could disqualify the patient.
Please type your name
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