Grant Application: Child (Ages 0-18)

Patient Information

Patient's Name: *

First

Last

Patient's Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Date of Birth: *

Patient's Gender: *

Male
Female

Patient's Cardiac Diagnosis: *

Patient's Primary Cardiologist: *

Patient's Primary Cardiologist Location: *

Patient's Insurance Provider (type 'None' if there is no insurance provider): *

Does the patient receive Medicaid? *

Yes
No
Maybe

The patient is requesting financial assistance for (choose all that apply): *

Travel for cardiac surgery/intervention
Cardiac medication
Cardiac-related medical equipment
Extended inpatient recovery

Surgery Date: *

Hospital: *

Prescribed Medications: *

Pharmacy Name: *

Equipment Description: *

Parent/Guardian Information

Parent/Guardian #1 Name: *

First

Last

Mailing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number: *

Email: *

Occupation / Employer: *

Parent/Guardian #2 Name (optional):

First

Last

Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number:

Email:

Occupation / Employer:

Grant Information

If this CHF of LA grant is approved, name of individual to whom the check should be made payable to: *

Mailing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Has the patient applied for financial assistance from our organization before? *

Yes
No
Maybe

Has the patient applied for financial assistance from other organizations in Louisiana? *

Yes
No
Maybe

Name of person completing this application: *

First

Last

Relationship to patient: *

Today's Date: *