Immediate Needs Fund – Request Form

ANNOUNCEMENT: TEMPORARY SCHEDULE CHANGE FOR WEEK OF August 20, 2018

Requests received before 5pm on Monday, August 20th will be reviewed by Wednesday, August 22nd. Notification of approved requests will be sent out before end of day Friday, August 24th.

Please note that any requests received after 5pm on Monday, August 20th will not be reviewed until Monday, August 27th when we resume our regular schedule.

The Employee Giving Committee accepts requests 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:
AltaMed Net Instruction
  • 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

FUND REQUEST FORM

Employee Information

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

PATIENT/PARTICIPANT INFORMATION

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

PATIENT/PARTICIPANT NEEDS

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!