Other Type of Application Guidelines
For any type of Medical Related Application or Quality of Life Item Application please reach out to us to find out what all may be required. This is the only way we can ensure the application will be processed. You can reach us by calling 855-219-1648 or my emailing firstname.lastname@example.org.
Due to the type of request we may require additional items to verify the need of assistance. However, you will still be required to provide the following, along with any additional items.
** For any quality of life requests, we require the service to be completed before paying the vendor. We are more than happy to speak with the vendor regarding payment arrangements if needed.
When submitting your applications please follow the detailed instructions outlined below.
This is the only way to ensure your application is reviewed and processed.
Before completing the application please review the following guidelines:
If you have access to Docusign, it may be used to obtain the required signatures. However, the instructions below MUST be followed!
Please follow the steps below to submit an Pediatric Relief Fund Application
* Applications must be submitted by a member of the patient's hospice or palliative care team.
** NOTE: We do NOT provide reimbursement for payments already made or items purchased
1. Download and complete the application
2. Review all the required items before your application is submitted
(We must have each of the items required before we process the application)
If you do not have access to your company letterhead you can use the HPCF approved verification form, which can be found by clicking the button below.
** This is NOT the preferred method, but is acceptable if there is no other option.
An email verifying the patient's status is NOT allowed!
3. Once all required information is obtained, please submit the the application and other documents by emailing them in PDF form to email@example.com.
4. Please provide feedback for us to use for marketing purposes.
** If you require additional assistance please reach out to us by calling 855-219-1648 or by emailing us at firstname.lastname@example.org.