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
*
First Name
Last Name
Social Worker's Email Address
*
example@example.com
Social Worker's Phone Number
*
-
Area Code
Phone Number
Transplant Facility
*
Banner UMC - Phoenix
Banner UMC - Tucson
Dignity Health
Mayo Clinic
Phoenix Children's Hospital
Transplant Recipient's Name
*
First Name
Last Name
Transplant Recipient's Birthdate
-
Month
-
Day
Year
Date
Transplant Recipient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Transplant Recipient's Phone Number
*
-
Area Code
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
*
Recipient's Race
Caucasian (non-hispanic)
Hispanic or Latino
Black or African American
Native American
Pacific Islander
Recipient's Gender Identification
Male
Female
Has Recipient received a solid organ transplant?
*
Yes
On the waitlist for an organ
No
Date of Transplant
*
Type of Transplant
*
Heart
Lung
Intestine
Kidney
Kidney/Pancreas
Pancreas
Liver
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?
*
Utility payment
Medication or Co-pay
Insurance Premium
Rent/Mortgage
Car payment
Temporary Lodging
Why does the recipient need financial assistance?
*
Does the patient have insurance?
*
Yes
No
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.
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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.
*
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