Living Assistance Fund Application
The Living Assistance Fund was created to provide financial aid to organ transplant recipients to reduce their stress during their medical procedures. We do this by paying for basic living necessities like housing, utilities, medication and transportation to the hospital.
Social Worker's Name
Social Worker's Email Address
Social Worker's Phone Number
Banner UMC - Phoenix
Banner UMC - Tucson
Phoenix Children's Hospital
Transplant Recipient's Name
Transplant Recipient's Birthdate
Transplant Recipient's Address
Street Address Line 2
State / Province
Postal / Zip Code
Transplant Recipient's Phone Number
Transplant Recipient's email
By entering an email address, TCA has permission to add recipient to our email list to receive monthly newsletter.
Recipient's Total Monthly Gross Income (if currently none, enter Zero)
Recipient's Household Size
Hispanic or Latino
Black or African American
Recipient's Gender Identification
Has Recipient received a solid organ transplant?
On the waitlist for an organ
Date of Transplant
Type of Transplant
Transplant Center where the transplant was/will be performed if different than above:
Amount of Financial Assistance Requested (limit $500)
What help does the Recipient need?
Medication or Co-pay
Why does the recipient need financial assistance?
Does the patient have insurance?
Would the patient like free counseling for an insurance issue?
Yes, please contact them.
No thank you.
If Yes, who is the insurance provider?
Please submit a copy of the bill to be paid BEFORE requests for assistance are considered.
By typing your name below, you agree that your patient understands that payments are made directly to the service provider, property manager or landlord and not to the patient or transplant center. This is an application for a grant of up to $500 that the patient does not pay back. I hereby certify that the answers on this form are true and correct. I understand that a false statement could disqualify the patient.
Please type your name
Should be Empty: