Hearts in Heaven

APPLICATION FOR FINANCIAL ASSISTANCE

Please Print

PATIENT INFORMATION (completed by applicant)

First name: _________________________ Last name: ____________________________
Today’s date: ________________ Address: _____________________________________
City, State, Zip: ___________________________________________________________
Phone number: Home ( ) __________________Work ( ) ______________________
Cell ( ) _____________________ Email Address _______________________________
Date of birth: _____________ Marital Status: ___________________________________
Home Church: __________________________ Pastor: ___________________________

HEALTH INSURANCE INFORMATION (completed by applicant)

Do you have health insurance?  Yes  No
Are you a member of Thrivent?  Yes  No
If no, please indicate type of insurance: ________________________________________
Are prescription drugs covered?  Yes  No

HOUSEHOLD FINANCIAL INFORMATION (completed by applicant)

Are you currently employed?  Yes  No
Do you have a spouse that is currently employed?  Yes  No
Number of people in household: ____________________
FAMILY INCOME SOURCES (please check all that apply):
 Social Security (retirement)  Salary  Pension  Unemployment
 Public assistance  Short-term disability  SSD (Disability)  SSI
 Family/friends provide support  Other - specify ___________________________
TOTAL ANNUAL FAMILY INCOME: $______________
FAMILY ASSETS (provide total amount in all accounts apply):
Checking/Money Market: $________________ Savings/CD: $____________
IRA/403B/401K: $________________ Stocks & Bonds: $_____________
TOTAL FAMILY ASSETS: $_____________________

HEALTH CARE PROFESSIONAL INFORMATION (must be completed by your

health professional)
MD name: _______________________________________________________________
Hospital/Clinic: __________________________________________________________
Address: ________________________________________________________________
City, State, Zip: ___________________________________________________________
Phone: ( ) __________________________ Fax: ( ) _______________________________
Summary of Diagnosis: _____________________________________________________

Signature of MEDICAL PROFESSIONAL: __________________________________

Date: ________________
PLEASE DESCRIBE YOUR CURRENT SITUATION:

AMOUNT OF ASSISTANCE YOU ARE REQUESTING: $

TO THE APPLICANT:

To ensure that your application is processed, please attach a COPY of your most
recent medical bill that indicates the medical expenses not covered by your
insurance company.

Please note that this application must be completely filled out and ALL necessary documents
attached and received by us in order for the review process to be initiated by our foundation.
We will NOT process incomplete applications. Please review your application carefully for
accuracy and legibility before sending it to us.

Please be aware that it is impossible to help all of the applicants that apply. A
COMPLETED application does not guarantee that we will be able to donate funds, nor
does a denied application indicate lack of compassion or desire to help; it simply means that
we can not help at this time.

By signing below, I, ___________________________, certify that all of the

information in this application is true. Furthermore, I have included all necessary
documents and/or attachments with my application.

APPLICANT SIGNATURE_______________________________________________
DATE: ________________________

Mail your completed application and attachments to:

Hearts in Heaven
226 E. Mills Dr.
Lake Mills, WI 53551

If you have any questions about the application process, feel free to use the Contact
Us form on our website: www.heartsinheaven.org/contactus.html

God’s blessings from Hearts in Heaven!