Medical Grant

Please complete the form to the best of your ability. All responses will remain confidential. We encourage you to apply if you are seeking financial assistance for medical expenses, including but not limited to those related to cancer and mental health issues.

First name

Last name

Phone

Address

Medical Background: Please describe your current medical condition(s) or diagnoses. How long have you been dealing with this condition? What type of medical treatment or care do you require?

Financial Need: What is your current financial situation, and how does it impact your ability to cover medical expenses? Are you currently insured? If so, what is covered by your insurance and what is not?

Use of Funds: How do you plan to use the funds from this grant? (e.g., hospital bills, medications, therapy, assistive devices, home care, etc.)

Impact of Funds: How will receiving this grant impact your health and quality of life?

Additional Information: Are there any other factors you believe should be considered in your application? Do you have any supporting documents, such as medical bills, doctor’s notes, or insurance statements, that you would like to include?

How did you hear about this application and Hallie225?

Medical Grant

Please complete the form to the best of your ability. All responses will remain confidential. We encourage you to apply if you are seeking financial assistance for medical expenses, including but not limited to those related to cancer and mental health issues.

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