Utility Bill Application Guidelines
(Examples - electricity, gas, or water, please note We DO NOT COVER landline phone service, mobile phone service, internet service, or cable service).
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 a 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
** The bill or invoice must be in the adult parent or legal guardian's name and be the same location as the pediatric patient's primary residence for which the relief fund is being rewarded.
1. Download and complete the application
2. Review all 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 firstname.lastname@example.org
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 email@example.com.