Apply for Assistance

In order to qualify for assistance, a child must be medically involved;  i.e., currently or recently hospitalized or receiving ongoing medical treatment at a medical facility or at home through specialized nursing care.

Please have the social worker or health care professional assigned to your child fill out these necessary forms and fax or mail them back to us.   The “Patient Information Form” must be completed by a health care professional in order for us to process a request.