Substance Use Financial/Programming Assistance Application

Substance Use Financial/Programming Assistance Application
Date of the Application

MonthDayYear
Date
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Provider(s) at Ravenwood Health*
Annual Household Income (How much money does your family make in a year including employment, Social Security, Worker's Compensation, Unemployment...)*
How many people are in your household?*
What is your current Medical Coverage/Insurance? I*
Which grant are you applying for?*

Opioid/Stimulant GrantUnsure
Please identify what services you need assistance with:*

Medication for MAT/SUD Treatment (does not include mental health medications)Co-pays for treatment (individual, groups, peer support, case management, pharmacology)Drug ScreensTransportationOther
If you are requesting assistance with "other" please explain
Your application will be reviewed, and someone will be in contact with you regarding your eligibility. Please be aware that depending on your grant eligibility there may be additional steps needed (our opiate/stimulate funding requires a brief interview that you can do with a Ravenwood provider over the phone or in the office).

Funding is time limited and you will be notified when it is no longer available. There will be limitations on what is funded so please speak with your provider if oyu have questions. In addition, you are required to complete your annual income verification to move forward with the funding application. Should your insurance situation change please notify us as soon as possible.
By signing below, I certify that I have read the above statement and that the information I have submitted above is true and complete. *

Clear
After signing the form please hit the submit button at the bottom of the page. The section below this is for the Ravenwood Staff to complete. Thank you
Ravenwood Health Staff Use Only

Application approved for SORS GrantApplication approved for AUD--Ravenwood grantApplication approved for AUD--Board grantOther (indicate below)Application Not Approved
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