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 Name
Last Name
Social Worker's Email Address
*
example@example.com
Social Worker's Phone Number
*
Format: (000) 000-0000.
Transplant Facility
*
Banner UMC - Phoenix
Banner UMC - Tucson
Dignity Health
Mayo Clinic
Phoenix Children's Hospital
Other
Transplant Recipient's Name
*
First Name
Last Name
Transplant Recipient's Birthdate
-
Month
-
Day
Year
Date
Transplant Recipient's Address
*
Street Address
Street Address Line 2
City
State / 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
Caucasian (non-hispanic)
Hispanic or Latino
Black or African American
Native American
Pacific Islander
Other
Recipient's Gender Identification
Male
Female
Other
Has Recipient received a solid organ transplant?
*
Yes
On the waitlist for an organ
No
Date of Transplant
*
Type of Transplant
*
Heart
Lung
Intestine
Kidney
Kidney/Pancreas
Pancreas
Liver
Other
Transplant Center where the transplant was/will be performed if different than above:
Select one type of assistance - either a Pex Card for gas/grocery funds or Other Assistance
PEX Card for Gas / Grocery Assistance - $250
Enter amount up to $250
Other Assistance $750 Limit - enter amount requesting
Enter amount up to $750
What help does the Recipient need?
*
Utility payment
Medication or Co-pay (must provide Pharmacy or Doctor's Office phone number)
Insurance Premium
Car payment
Temporary Lodging (must provide hotel phone number, name on reservation or reservation confirmation number)
Gas / Transportation
Groceries
Assistance with Medicare / Social Security Filing
Medical Debt Counseling
Rent / Mortgage (verify if landlord accepts partial payment and how to make payments)
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?
*
Yes
No
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 $750 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.
*
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