Monday to Friday 9:00 A.M. - 5:30 P.M.

Saturday and Sunday - CLOSED

661 404 4748

info@csffoundation.org

3811 Mt. Vernon Ave.

Bakersfield, CA 93306

Application for a Surgery

CSF Medical Non-Profit Foundation´s health services are ONLY for medically uninsured individuals. Applicants must be a Cirugia Sin Fronteras (CSF Surgery) patient before applying, must have a medical diagnosis and must have been seen by a CSF´S surgical Specialist. For more information regarding eligibility please call 661-335-5746 Monday through Friday from 9:00 A.M. to 5:30 P.M. (PST). This form is to apply for no charge or reduce cost for surgery and only applies to existing CSF Surgery Patients. reduce cost for surgery and only applies to existing CSF Surgery Patients.



Please indicate the type of surgery:



Household information:



Member 1



Member 2



Member 3



Member 4



Work or employment information:



If working, please complete the following:



IF UNEMPLOYED



Income information



Please list all household incomes. One for each member of the household that is employed:



If yes, please complete the following:



Personal Information and Disclaimer Statement



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.

I, the applicant, declare under penalty of perjury, under the laws of the state of California and The United States of America, that the information given in this data statement are true, correct, and complete.




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