Caring Hands in Health

Caring Hands in Health

Application Form
Reminder:

PATIENTS CANNOT SUBMIT AN APPLICATION FORM. REQUESTS MUST BE MADE BY A SAN MATEO COUNTY HEALTH OR PUENTE STAFF MEMBER.

PLEASE READ THE FULL CARING HANDS IN HEALTH POLICY BEFORE SUBMITTING AN APPLICATION.
I am a Puente staff member and the client is a patient of San Mateo County Health.
YesNo
We regret to inform you that we are unable to process your application. Our financial assistance program is designed to support active patients of San Mateo County Health, as per our established bylaws.

If you have any questions or require further assistance, please do not hesitate to reach out at (650) 573-2655 or email us at info@smchf.org

Please disregard the requirements below. You can now exit the application.
Include the name of the patient's San Mateo County Health medical team member*

First and Last NameRole/Title
Application Date*

MonthDayYear
Date
Patient Information
Patient Name*

First NameMiddle NameLast Name
Patient Guardian Information (if applicable)

First NameLast Name
Patient Guardian Relationship to Patient
Phone Number*
Please enter a valid phone number so we can reach the patient (or guardian).Format: (000) 000-0000.
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email
Patient Date of Birth*

MonthDayYear
Date
Patient Medical Number*
e.g., SMMC MRN, Avatar, etc.
Patient Demographics

The data below is for aggregate use when we apply for grants to further the program. It will in no way determine the status of the patient's application.
What is the patient's primary language?*
Secondary language, if applicable
MaleFemaleNon-binaryDecline to StateOther
WhiteHispanic or LatinoBlack/African AmericanAsian/Pacific IslanderMulti-RacialDecline to StateOther
SingleMarriedWidow/WidowerDivorcedSignificant OtherDomestic PartnerDecline to StateOther
Staff Referral

Any staff member from San Mateo County Health and Puente de la Costa Sur can submit an application on behalf of a San Mateo County Health patient. A Provider is no longer required to confirm if the patient is in need of the assistance requested.
Name and Title/Role of SMCH Staff Member Submitting Request on Behalf of Patient *

First and Last NameTitle/Role
Department*
Email*
example@example.com
Signature*

Clear
Yes
Name and Title/Role of PUENTE Staff Member Submitting Request on Behalf of Patient*

First and Last NameTitle/Role
PUENTE Staff Member Email*
example@example.com
PUENTE Staff Member Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PUENTE Staff Member Signature*

Clear
Basic Living Necessities (i.e., groceries, personal care items, baby items)Medical Needs (i.e., prescription copay, dental procedures, accessibility equipment, etc.)Emergency Housing Assistance (For those in jeopardy of being evicted or requesting temporary lodging)Senior Meals on Wheels (For people 60 years old or above - see restrictions on website.)Transportation (To and from medical appointments only)
Please explain the patient's need for assistance. BE AS SPECIFIC AS POSSIBLE and include any links to items being requested (if applicable). *
Please explain the patient's need for Senior Meals on Wheels.
YesNo
YesNo
Date of the appointment *

MonthDayYear
Date
What time is the appointment?*

Hour Minutes

AM/PM Option
What type of medical appointment is this?*
What is the approximate duration of the appointment?*
Approved rental assistance and temporary lodging is given on a one-time basis, and is meant to be a temporary solution while the patient is working on a more permanent solution. The patient must also be linked to a social worker. Payment will be made directly to patient's landlord or to the hotel property.
Rental AssistanceTemporary Lodging
Please describe the situation and why temporary lodging is necessary. *
Please note, our partner hotel is located in Burlingame.
Check-In Date Requested for Patient's Temporary Lodging*
Please provide check in date.
Check-Out Date Requested for Patient's Temporary Lodging*
Please provide check out date.
Please describe the patient's situation and why they are in need of rental assistance. Include the amount of their current rent. *
The Foundation does not cover overdue rent, late fees, or security deposits.
Patient's Monthly Rent*
Enter the monthly amount the patient is responsible for paying. The Foundation covers up to half of this amount.
Patient Landlord's Name*
YesNo
If the Landlord is related to the patient, please specify the relationship.*
Patient Landlord's Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
What is the patient's plan for a long term solution if granted the rental assistance award?*
YesYes, I am the patient's social workerThey are not, but I have referred the patient to a social worker
Name of Social Worker*
Name of the social worker assigned or referred to the patient.
Additional Comments
YesNo
Patient or authorized individual on behalf of patient has given consent
I, Patient Name , authorize the disclosure of the above identifiable information from the San Mateo Medical Center (SMMC) to the San Mateo County Health Foundation (Foundation), for the purpose of applying for the Caring Hands in Health program. No patient personal health information (PHI) will be released pursuant to this application. The Foundation will use the information solely for the purposes of processing this application. I, Patient Name* ,attest that if provided funds for the purpose listed above, I will use the funds or the stated purpose.
Patient or Guardian Signature*

Clear
Date*

MonthDayYear
Date of consent
Should be Empty:

Caring Hands in Health

Patient Information

Patient Demographics

Staff Referral