Heartworm Assistance Application

Heartworm Assistance Application
Guidelines for Assistance:
1. The animal must originate from Hillsborough County Pet Resource Center (Hillsborough County Shelter)
2. The pet must test positive for heartworms at the shelter or immediately after leaving the shelter.
3. FoHCAS must be contacted within a reasonable length of time after animal leaves the shelter. Reasonable usually means within a week, but exceptional circumstances are taken into consideration.
4. Our assistance is based on discounted rescue/non-profit rates.
5. All payments from FoHCAS are made directly to the Veterinarian who provided service. FoHCAS cannot reimburse or make payment to a pet owner.
Click to Expand Each Required Section Below

All sections are required to complete the form. Sections must be completed in sequential order, and all information flagged with a red star is required in order to submit the form.

Pet Owner / Foster Information
Name*

First NameLast Name
Email (enter email twice)*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number

Pet Information
Indicate Your Dog's Heartworm Status (from Adoption Papers or testing at your Vet):*

Heartworm PositiveHeartworm Negative
STOP HERE. This form is only to request assistance with Heartworm treatment.

If your pet is not Heartworm Positive but needs other medical treatment, please return to the FOHCAS website and select the option for "Other Medical Assistance"
Dog's Name*
Your Dog's Permanent Name - may be different from their shelter name
Dog's Name at the Shelter*
Your Dog's Name at the Shelter. If you did not change your dog's name, just re-enter their name here.
Animal ID# from Pet Resource Center (Hillsborough County Shelter)*
Enter Animal ID# from your pet's adoption papers (e.g. A1234567)
Date Adopted from Pet Resource Center (Hillsborough County Shelter)*
mm-dd-yyyy
Breed*
Enter Breed listed on your pet's adoption papers
Color*
Enter Color listed on your pet's adoption papers
Sex*

MaleFemale
Approximate Age*
Enter Approximate Age listed on your pet's adoption papers
Select Your Pet's Weight Category:*

Under 50 Pounds50 Pounds or More
Weight*
Weight in Pounds

Treating Veterinarian/Clinic Information
Heartworm treatment is available through the Humane Society of Tampa Bay, or from another Approved Veterinarian of the Owner/Foster’s choice.
Your Selection of Veterinarian:*

HUMANE SOCIETY OF TAMPA BAY (“HSTB”): FoHCAS will sponsor treatment at the rate of $200 for pets under 50 pounds or $300 for pets 50 pounds or greater. We ask that Owner/Foster pay as much of this cost as they can, and FoHCAS will pay the remaining cost, up to 100% of the amount. This rate does not include the cost of the recommended antibiotic – the antibiotic cost is the responsibility of the owner/foster.OTHER APPROVED VETERINARIAN: FoHCAS will pay Owner/Foster’s approved veterinarian up to the amount that would have been paid to HSTB – up to $200 for pets under 50 pounds or up to $300 for pets over 50 pounds. Note: it is recommended you confirm the cost prior to making a choice of HSTB vs. other Approved Veterinarian. Prices vary and can be quite expensive.
Veterinarian Name*
Veterinarian Email*

Confirmation Emailexample@example.com
Veterinarian Phone*

Area CodePhone Number
Attach Copy of Veterinarian's Treatment Plan and Cost Estimate

Browse Files

Cancelof

Payment Information - Humane Society
Treatment cost at the Humane Society for your pet will be $200, based on your pet's weight of less than 50 pounds. Reminder: This amount does not include cost of recommended antibiotic that is the responsibility of the Owner/Foster.

FOHCAS can pay up to $200 of the treatment cost; however, we ask that Owner/Foster pay what they can (no matter how small), so we can assist other pets in need. All payments will be made directly to the Humane Society of Tampa Bay.
Treatment cost at the Humane Society for your pet will be $300, based on your pet's weight of 50 pounds or more. Reminder: This amount does not include cost of recommended antibiotic that is the responsibility of the Owner/Foster.

FOHCAS can pay up to $300 of the treatment cost; however, we ask that Owner/Foster pay what they can (no matter how small), so we can assist other pets in need. All payments will be made directly to the Humane Society of Tampa Bay.
Amount Owner/Foster Will Pay:*
Indicate the amount you will pay toward the treatment. If you are requesting FOHCAS pay 100% of the cost indicated above, enter 0 (zero) in this field.
Amount Requested FOHCAS Pay:*
Automatically calculates based on Amount entered in the Amount Owner/Foster Will Pay field ;
Amount Owner/Foster Will Pay:*
Indicate the amount you will pay toward the treatment. If you are requesting FOHCAS pay 100% of the cost indicated above, enter 0 (zero) in this field.
Amount Requested FOHCAS Pay:*
Automatically calculates based on Amount entered in the Amount Owner/Foster Will Pay field ;

Payment Information - Other Veterinarian
FoHCAS can contribute up to $200 toward the treatment cost, based on your pet's weight of less than 50 pounds. We ask that Owner/Foster pay what they can (no matter how small), so we can assist other pets in need. All payments will be made directly to the treating veterinarian.
FoHCAS can contribute up to $300 toward the cost of treatment, based on your pet's weight of 50 pounds or more. We ask that Owner/Foster pay what they can (no matter how small), so we can assist other pets in need. All payments will be made directly to the treating veterinarian.
Total Treatment Amount:*
Enter the total treatment amount from your veterinarian's estimate/treatment plan.
Amount Owner/Foster Will Pay:*
Indicate the amount you will pay toward the treatment.
Amount Requested FOHCAS Pay (based on contribution amount above): *
FOHCAS can pay up to 100% of the contribution amount indicated above ($200). However, we ask that Owner/Foster pay what they can so we can assist other pets in need.
Amount Requested FOHCAS Pay (based on contribution amount above): *
FOHCAS can pay up to 100% of the contribution amount indicated above ($300). However, we ask that Owner/Foster pay what they can so we can assist other pets in need.
Other Comments
Provide any additional comments or questions here

Electronic Signature
DISCLAIMER AGREEMENT: FoHCAS agrees to pay only for the above treatment(s) performed by the Approved Veterinarian on the designated pet, not to exceed the Estimated Expense. Actual amount paid by FoHCAS will be communicated via Confirmation Email to Owner/Foster and Approved Veterinarian. The veterinary bills for Treatment listed above will be paid directly by FoHCAS to the Approved Veterinarian. Owner/Foster will promptly remit copies of all invoices to FoHCAS for payment and/or make advance arrangements for FoHCAS to be invoiced directly. (Note: Owner/Foster does not need to submit invoices for treatment provided by the Humane Society of Tampa Bay.)

Any treatments or medications not listed above will not be covered by FoHCAS and will be the sole responsibility of the Foster/Owner.

Owner/Foster understands that FoHCAS is not a medical provider and makes no representations or warranties, express or implied, regarding any medical care or treatment provided by the Approved Veterinarian. By his/her signature below, Owner/Foster authorizes the Approved Veterinarian to disclose any medical records or health care information related to diagnosis listed above to FoHCAS upon request.

ELECTRONIC SIGNATURE: By providing your electronic signature below, you acknowledge that:
- You have provided accurate information to the best of your ability
- You have read and understood the disclaimer agreement above
Electronic Signature*
Type your Electronic Signature here
You will receive a confirmation screen after successfully submitting this form. If you do not get the confirmation screen, please re-check the body of the form for areas marked in red that need to be corrected.
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Heartworm Assistance Application

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