Caring Hands in Health

Caring Hands in Health

Application Form
Important Reminder:

PATIENTS CANNOT SUBMIT AN APPLICATION FORM. REQUESTS CAN BE MADE BY ANY SMMC STAFF MEMBER, BUT MUST BE CONFIRMED BY A SMMC PROVIDER.
Application Date*

MonthDayYear
Date
Name and Role/Title of SMMC Staff Member Submitting Request On Behalf Of Patient*

First and Last NameRole/Title
The provider is fully aware of the patient's condition and has recommended the requested assistance.*

Yes
Patient Provider Name*

First NameLast Name
Patient Information
Patient Name*

First NameMiddle NameLast Name
Medical Record Number (MRN)*
Patient Date of Birth*

MonthDayYear
Date
Patient Guardian Information (if applicable)

First NameLast Name
Patient Guardian Relationship to Patient
Patient/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient/Guardian Phone Number*
Please enter a valid phone number.
Patient/Guardian Email*
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.
Gender:*

MaleFemaleNon-binaryDecline to stateOther
Race/Ethinicity:*

WhiteBlack/African AmericanAsian/Pacific IslanderMulti-RacialHispanic or LatinoDecline to stateOther
Relationship Status*

SingleMarriedWidow/WidowerMarried & SeparatedDivorcedSignificant OtherDomestic PartnerDecline to stateOther
What is the patient's primary language?*
Secondary language, if applicable
Provider Referral
The patient is requesting assistance for:*

Basic Necessities (i.e., groceries, medical and accessibility equipment)Emergency Housing AssistanceMedical Billing Assistance (i.e., prescription, dental procedure, insurance premium/deductible)
I (SMMC staff member or SMMC provider) attest there is no concern that this assistance might be used for any alcohol or drug addiction.*

Yes
Please explain the patient's need for assistance. BE AS SPECIFIC AS POSSIBLE and include any links to items being requested. Financial assistance is given up to $500 for basic needs like groceries, medical and accessibility equipment, and other out-of-pocket expenses related to or directly caused by a medical issue; Emergency Housing Assistance for those in need or with children and elderly in the home; and medical billing assistance with prescriptions, dental procedures, and insurance premiums/deductibles.*
Please clearly demonstrate the patient's need in detail.
IF THE PATIENT IS REQUESTING EMERGENCY HOUSING ASSISTANCE, PLEASE LIST THE AMOUNT OF RENTAL ASSISTANCE NEEDED. Approved housing assistance is given on a one-time basis, and is meant to fill the gap for no more than a month of rent while the patient is working on a more permanent solution. Payment will be made directly to the patient's landlord. Please include the name and contact information below.
Amount of Emergency Housing Assistance Requested
Please enter actual dollar amount.
Patient Landlord's Name
Patient Landlord's Phone Number
Please enter a valid phone number.
Delivery*

Patient will pick up item requestedItem requested must be delivered to the patientEmergency Housing Assistance will be paid to patient's landlordOther
Note: We do not give cash to patients and gift cards are given on a per case basis. Payment is made directly to a merchant or business to pay for the goods/services requested. Approved housing assistance is paid directly to a patient's landlord.
Additional Comments:
Patient Consent

I authorize the disclosure of the above identifiable information from the San Mateo Medical Center (SMMC) to the San Mateo 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 attest that if provided funds for the purpose listed above, I will use the funds for the stated purpose.
Patient Name*

First NameLast Name
Patient or Guardian Signature

Clear
Verbal Patient Signature (Mark if patient is on a virtual or phone appointment)

Patient or authorized individual on behalf of patient has given consent
Date*

MonthDayYear
Date
SMMC Staff Member or Provider Full Name*

First NameLast Name
SMMC Staff Member or Provider Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Caring Hands in Health

Patient Information

Patient Demographics

Provider Referral

Patient Consent