Full name
DOB
Address
City
State
Zip Code
E-mail
Phone number
Do you currently have Health Insurance?
YES NO
Have you seen a specialist?
YES NO
Name of Doctor
Name of clinic or practice
Phone number
If no, please indicate the reason:
No medical insurance No medical reference No enough money to pay Other
Please indicate the type of surgery:
Type of surgery
Please describe your current symptoms
Household information:
Marital status:
Maried Divorce Single Widower Other
Number of household members:
Member 1
Full Name
Relationship to applicant
DOB
Member 2
Full Name
Relationship to applicant
DOB
Member 3
Full Name
Relationship to applicant
DOB
Member 4
Full Name
Relationship to applicant
DOB
Work or employment information:
Working status:
Full time Part time Unemployed
If working, please complete the following:
Employer/Company
Supervisor’s name
Employer phone number
Job title
Describe what you do, your duties or responsibilities
IF UNEMPLOYED
If unemployed, please indicate for how long:
Income information
Members of household currently working:
Please list all household incomes. One for each member of the household that is employed:
Name
Employer
Employer’s phone number
Monthly income
Name
Employer
Employer’s phone number
Monthly income
Name
Employer
Employer’s phone number
Monthly income
Does anyone in your household receive any personal or governmental income assistance of any kind?
YES NO
If yes, please complete the following:
Name
Type of aid
Amount received
How often
Name
Type of aid
Amount received
How often
Name
Type of aid
Amount received
How often
Please upload a copy of your last 3 pay stubs or last 2 months bank account statements
Personal Information and Disclaimer Statement
Are you escaping from the law to avoid persecution for a major felony or to avoid being arrested after a conviction, or for a probation violation?
YES NO
If yes, please explain:
Have you been convicted for a major felony related to drugs (including marijuana) and/or alcohol?
YES NO
If yes, please explain:
Have you completed a drug and or alcohol treatment program certified by the government?
YES NO
If yes, please explain:
I understand all questions on this form. I understand and agree that all information provided, including information about benefits and income will be verified and that I will have to provide the necessary documentation to verify the given information. I understand that my case eligibility will be based on the information given in this application including all additional information if requested by CSF Medical Non-Profit Foundation. I understand that my case could be reviewed more than once in order to determine eligibility. I also understand that the Board of Directors thoroughly study all cases and there is a possibility my case won’t be accepted and be rejected.
Applicant Initials:
Documents Upload
Picture ID (driver’s license, passport, consular registration, etc.)
Proof of address (Utility bill, proof of rent or mortgage)
Tell us about your story
This is your opportunity to tell us in detail about your health problems, why you need help, your economic situation and other information that you consider relevant and important mentioning.
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