Medical Grant Application : Medical Grants : What We Do : Project 4:7

Grant Request Form

Today's Date (Required)

Name of Potential Grant Recipient

First Name *

Last Name *

Street Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Your Email (Required)

Home Phone (Required)

Cell Phone

Work Phone

Work Phone

ext Extension

Contact Preference

Email
Phone

Please explain medical treatment needed and describe financial hardship. How would the funds be used to help empower the recipient to help himself or herself? (Required)

Income Verification & Outstanding Medical Bills

Attach income verification information and/or outstanding medical bills related to mental health treatment. Note: only bills less than 30 days past due are eligible for grant reimbursement.

Please provide the following information when submitting a patients outstanding medical bills:

Patient's date of birth
Itemized page with the name of the organization to be paid
Provider phone number
Account # on claim
Date of service
Amount to be paid.

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Grant Project 4-7 Permission

Please print and sign this statement to give the Project 4:7 Foundation permission to talk to the billing department of the organizations listed.

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