Please note that all funds for November have been exhausted and all requests submitted for the month will be not reviewed by the committee until Early December.

Thank you.

 

Before submitting a request for patient/participant support through AltaMed GIVES’ Immediate Needs Fund, please review the available resources below. Note: resources below are for Managed Care patients only. If your request is for a non-managed care patient, please proceed to Section B of the form.


Section A

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

 

  • 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

Section B

Please provide all of the information requested below. ** Note: AltaMed employees and immediate family members (including domestic partners, brothers/sisters, aunts/uncles, nieces/nephews, cousins and grandparents) are not eligible for this program. **

EMPLOYEE INFORMATION


Name
Email
Employee Work Site

PATIENT/PARTICIPANT INFORMATION


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

PATIENT/PARTICIPANT NEEDS


You will receive a response after request is reviewed by 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!

 

Program Guidelines

General Eligibility for Patient/ParticipantThe Development team will remove any identifying patient information before sending out for vote.

  • Name of Recommender (Active AltaMed Employee)
  • Patient/Participant Age Range
  • Marriage Status (if applicable)
  • Number of people in household
  • Number of dependents
  • Number of Children under 18
  • Household income (No proof necessary)
  • Number of years as an AltaMed patient
  • Verification of need (if applicable)
  • Cannot be an AltaMed employee
  • Cannot be an immediate family member of an AltaMed employee (including domestic partner, aunt, uncle, cousin, niece, nephew, and grandparents)

Goal

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

Eligible Needs

  • Food & Related items
  • Specialist Appointment Co-Pay
  • Medication/Rx Co-Pay
  • Transportation to Specialist Appointment
  • Seasonal clothing (jackets, shoes)
  • Home Essentials

Dollar amount provided

  • $1,000 per month – Dollar amount is for all sites
  • Patient/ Participant can receive amounts of $25, $50, $100, $250 or other