INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED
Description of Needs
PLEASE UPLOAD A COPY OF YOUR RECENTLY FILED INSURANCE CLAIM FORM WITH THIS APPLICATION.
Maximum individual grants shall not exceed $10,000.
Apply early as funds are limited.
Below is where you can upload your insurance claim form and a current W-9 form.
CERTIFICATION BY APPLICANT
I certify that I have suffered damage to my medical practice and that the information contained in this application is true and complete. I understand that a material misrepresentation or omission of any information requested is grounds for denial of grant assistance under this program and also would be grounds for demand for return of any grant assistance.
I hereby request and authorize agents of the Foundation for Healthy Floridians Disaster Relief Program to review all appropriate documentation that is deemed necessary in connection with my application for assistance.
I understand that submission of an application for assistance is not an entitlement and that the Board of the Foundation for Healthy Floridians shall have sole discretion in determining whether I receive assistance.
If you were not able to upload the supporting documents, please forward your completed and signed application, your insurance claim and a current W-9 form by mail or fax to:
Foundation for Healthy Floridians1430 Piedmont Dr. EastTallahassee, FL 32308Fax: (850) 222-8030