Mail: P.O. Box 911074
Lexington, KY 40591
Phone: (859) 509-9857
Kerrington's Heart primary mission is to provide encouragement, support, and education to the children and families affected by heart disease. We would love the opportunity to provide emotional support during your journey.
**Please make sure the medical release is signed and submitted with application
If requesting public transportation or UBER services please specify how many adults and/or that will be traveling
**Those requesting UBER services will be required to sign the UBER Terms and Agreement
I hereby agree to enclose all information and to complete this application honestly and fully. All above information is true and accurate to the best of my knowledge. I understand that by completing this application, Kerrington's Heart may request additional information necessary to determine my eligibility. If any of the above information is found to be untrue or falsified, I understand my application will be denied and I may be ineligible for future assistance. By completing this application, you are giving permission for a member of Kerrington's Heart to contact you.
In order for riders to enjoy safe and comfortable rides, drivers maintain clean vehicles. Riders are responsible for damage to the interior or exterior of a vehicle caused by incidents such as vomiting or food spills while in a driver's vehicle.
Cleaning fees are assessed and charged by UBER according to the extent of the damage. These fees will be charged to Kerrington's Heart by UBER but will be required for reimbursement by patient. Those failing to pay may be ineligible for future assistance.
Once we have a completed application with all needed paperwork, your application will be presented to the committee. From there, it usually takes 5-7 days for a decision to be made.
We need a valid Kentucky issued driver's license or other state issued identification.
Letter from doctor or social worker (on letterhead) that includes the child's diagnosis, history of illness, and specific request for funding.
The first page of your most recent tax return or W-2 for both applicant and spouse, recent pay stubs from all working parents/guardians, and a copy of any additional income such as social security, disability, etc.
Copy of all bills requesting assistance
We CAN review any bills for household expenses or bereavement costs. We will NOT look at any bills older than 90 days. We do NOT help with vehicle repair, therapy costs, medical bills, or medical equipment.
We require a new application every year
We will contact you via phone or email
If we have further questions about diagnosis or treatment plan, the medical release form allows us to call your doctor or social worker and ask about patient information. This often times helps us to support the families better.
We treat every application on a case by case basis. Each application is looked at individually to determine the need.
I give Kerrington's Heart, Inc. permission to release and/or request medical records on the above-named patient, and hereby declare that I am the legal guardian of the above-named patient.
Kerrington's Heart, Inc. may request information (any information received will be kept confidential) from:
I understand that I may revoke this consent at any time; however, said revocation cannot be applied retroactively after the information has been released in good faith.