lendahand

LEND A HAND UP FUNDRAISER REQUEST

PART 2 - FAMILY SIGN OFF

Consent and Information About Medical Challenges

Should be completed by individual or parent/guardian

receiving help.
Please review the fundraiser and boost criteria HERE or find it on the "Start a Fundraiser" page at LendAHandUp.org before proceeding with the Lend A Hand Up Request.

Have the following information available to complete the application. Please forward documentation to the Lend A Hand Up office.
- Information about the child or adult currently experiencing a debilitating illness, injury, or traumatic event resulting in substantial out-of-pocket expenses of $5,000 or more.
- Documents verifying local residency, name, age (driver's license or birth certificate)
- Documents verifying medical diagnosis/condition and provider (letter from doctor or discharge statement).
If you'd prefer to print and complete a request on paper, do not use this form; instead use the attached printable PDF request.

To forward documentation or if you have questions about required information and guidelines, please contact the program office: jpeinovich@dakmed.org or 701-356-2661. Fax: 701-271-0408.
Part 2 Printable PDF (Right click on PDF image, then print or save as.)
Name *

First Name Last Name

Section 2A:

Information about child or adult currently experiencing a debilitating illness or injury, or who recently suffered a traumatic event resulting in substantial out-of-pocket expenses of $5,000 or more.
Recipient Name *

First Name Last Name
Age *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County Residency *

Cass (ND) Clay (MN) Becker (MN)
Number of years living in current county: *
Cell Phone *
Other Phone
E-mail *
Name of Employer *
N/A if not employed
Names of other individuals living in the same household; if children, include their ages

Section 2C: Out of Pocket Expenses (NOT Covered by Insurance)

Out of pocket expenses include expenses NOT covered by insurance or other programs and include medical bills as well as prescriptions, supplies, mobility devices, home adaptations, gas and lodging (if seeking medical care out of area), and other nutritional/health necessities.
Due to medical challenges or recent physical trauma, do you expect your out of pocket expenses and/or your loss of income to exceed $5,000? *

Yes No
Explain: *

0/500

Out-of-Pocket Expenses

Out-of-Pocket Expenses Past 12 Months

Estimated Out-of-Pocket Upcoming 12 Months

Medical Care (Provider, Lab, Radiology, Inpatient/Hospital)

Prescriptions/ Equipment/Supplies

Health Insurance - cost (if any) you pay to maintain coverage (Your premium/liability expense per month x number of months)

Travel/Gas (Based on $0.25/mile x number of miles x number of trips)

Lodging/Food (If you receive medical care out of area, estimate costs based on $125/person or $200/family x number of days there

Enter the total of the above five rows

(Optional) - Non-Medical Expenses Increasing Financial Hardship Due to Medical Condition and Lost Wages. Example: mortgage/rent, food, daycare, auto, etc.

Out-of-Pocket Expenses Spreadsheet
If receiving out of area medical care, what facility and city?
Who is responsible for payment of out of pocket expenses? *
Have you received prior funding from Lend A Hand/Up? *

Yes No
If yes, when?

Month Day Year

Section 2D: Recipient Signature
REMINDER: Don't forget to mail, email, drop off or fax:
- Documents verifying local residency, name, age (photo ID or birth certificate)
- Documents verifying medical diagnosis/condition and provider (letter from doctor or discharge statement).
Please ensure that the Part 1 - Request for Boost Funding has been completed by a committed and caring person willing to serve as the champion for this fundraiser (should be someone outside of your/recipient's household).

If a Lend A Hand Up representative has not confirmed that your application was received within 3 days of submission, please contact the program office.

Staff:
Jeana Peinovich, Lend A Hand Up Director
(701) 356-2661, jpeinovich@dakmed.org
Heather Hanson, Lend A Hand Up Coordinator
(701) 356-3138, heatherhanson@dakmed.org

Address:
4141 28th Ave S, Fargo, ND 58104

Fax:
(701) 271-0408
Signature *
Full Name
Date *

Month Day Year
Should be Empty: