Caring Hands in Health
Application Form
Please note: If the recipient of the Caring Hands in Health program assistance is a minor their parent or guardian will be required to sign their consent.
Application Date
*
-
Month
-
Day
Year
Date
Provider Name
*
First Name
Last Name
Patient Applicant Information
*
First Name
Middle Name
Last Name
Patient Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Patient Guardian Information (required if patient is under the age of 18)
First Name
Last Name
Patient Guardian Relationship to Patient
Applicant/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant/Guardian Phone Number
*
Please enter a valid phone number.
Applicant/Guardian Email (Optional)
example@example.com
Patient Demographics (Optional)
The data below is to be used for aggregate use and will in no way determine the status of the patient’s application.
Gender:
Male
Female
Non-binary
Decline to state
Other
Race/Ethinicity:
White
Black/African American
Asian/Pacific Islander
Multi-Racial
Hispanic or Latino
Decline to state
Other
What is the applicant's primary language?
Secondary language, if applicable
Relationship Status
Single
Married
Widow/Widower
Married & Separated
Divorced
Significant Other
Domestic Partner
Decline to state
Other
Provider Referral
Please explain the patient's need for assistance.
*
Please cleary demonstrate the patient's need in detail.
Financial Assistance Requested:
*
$100
$200
$350
$500
Other
Assistance is preferred to be distributed via gift card but each grant will be done on a case by case basis. Please note if there are any accessibility concerns or recommendations:
Additional Comments:
Distribution and Accessibility
*
Patient has the ability to pick up assistance
Assistance must be delivered to the patient
Other
Is there any concern that this assistance might be used for any alcohol or drug-related purposes?
*
Yes
No
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.
Print Name
*
First Name
Last Name
Patient or Guardian Signature
Clear
Verbal Patient Signature (For virtual or non in-person appointments)
Phone consent by Patient or Individual Authorized to Consent Full Name
Date
-
Month
-
Day
Year
Date
Provider Signature
*
Clear
Provider Full Name
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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