General Medical Assistance Application

General Medical Assistance Application
Guidelines for Assistance:
1. The animal must originate from Hillsborough County Pet Resource Center (Hillsborough County Shelter)
2. The medical condition must be known at the time of adoption.
3. Medical condition must be treatable. We will not assist with chronic or terminal conditions. We will assist with the payment for biopsies or other diagnostics to determine condition as long as the owner is aware of the above caveat.
4. FoHCAS will not assist with normal, routine medical issues (i.e. yearly exams, shots, monthly heartworm prevention, etc.)
5. 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.
6. Our assistance is based on discounted rescue/non-profit rates.
7. 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
This form is only to request assistance with General (non-heartworm) treatment.

If your pet is also Heartworm Positive and you need assistance with heartworm treatment, please return to the FOHCAS website and select the option "Apply for Heartworm 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*

MaleFemaile
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
Medical 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”)OTHER APPROVED VETERINARIAN: 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 (enter email twice)*

Confirmation Emailexample@example.com
Veterinarian Phone*

Area CodePhone Number
Diagnosis and Treatment Plan. Describe the formal diagnosis of condition/illness and treatment/medication required.*
Information from adoption papers or from your vet
Attach Copy of Veterinarian's Treatment Plan and Cost Estimate*

Browse Files

Cancelof

Payment Information
FoHCAS can contribute up to a maximum of $500 toward the treatment co per pet, depending on the type of treatment needed. 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: *
FOHCAS can pay up to a maximum of $500 per pet, depending on the type of treatment. 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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General Medical Assistance Application

Click to Expand Each Required Section Below