Immediate Needs Fund – Request Form

Review process updated!!

EFFECTIVE: May 1, 2018, due to the increase in requests, the Employee Giving Committee is accepting requests for review on Mondays and Wednesdays. Once an employee submits a request, they will receive a response within 72 hours of the request being reviewed.

Program guidelines

To assist patients/participants who do not have access to basic necessities that affect their health and well-being.

Those who do not qualify for this program:

AltaMed employees including: contractors, per diem, interns and/or AltaMed fellows
Family members of an AltaMed employee (including domestic partner, children, siblings, aunts, uncles, cousins, nieces, nephews, and/or grandparents)

Examples of eligible needs are:

Food & related items
Specialist appointment co-pay
Medication/Rx co-pay
Transportation to specialist appointment
Seasonal clothing (jackets, shoes)
Home essentials

Is this a Managed Care patient?

Services and support are available for our managed care patients and can be accessed by sending a referral to the Medical Management Department. Below are examples of resources available through AltaMed Net[Link Coming Soon]:

Community Based Adult Services
Home Environment
Low Income Utility Resources
In Home Supportive Services (IHSS)
Transportation

Disability Resources
Foundation Referrals
Low Income Eye Glasses Resources
Long-Term Services and Support (LTSS) / Multi-Purpose Senior Services Program (MSSP)
Substance Abuse

Food Resources
Housing Resources
Low Income Funeral Benefits Resources
Mental Health
SSI Benefits Information

Fund Request

If you are human, leave this field blank.

FUND REQUEST FORM

Employee Information

This information is needed so that we can contact you if your request is approved.

Recommender: (Employee Name) *

Employee Email *

Employee Work Site *

PATIENT/PARTICIPANT INFORMATION

Insurance Status *

Marriage Status *

Number of Dependents *

Number of Children under 18 *

Number of People in Household *

Household Yearly Income *

Age Range *

Has been an AltaMed patient for *

Please state an explanation or description of the need and the reasoning for requesting additional resources (DO NOT INCLUDE PATIENT NAME or any PHI). For example, patient needs assistance with groceries for the month. *

Please send any additional documents verifying need to [email protected]

PATIENT/PARTICIPANT NEEDS

Dollars Distributed via:

Terms *

I agree that I have not included any information that uniquely identifies the patient in this form or in the description of the patient’s needs.

Text

You will receive a response after the request is reviewed by the Employee Giving Committee, no earlier than a week after submission. If you have any questions, please email [email protected]. Thank you for being an advocate for the community we serve!