Mica Hammond Fund | G-tube diets form

RETURN TO MICA HAMMOND FUND MAIN PAGE

Mica Hammond Fund G-Tube Blended Diet Reimbursement:

The Mica Hammond Fund intends to give awards totaling approximately $2000 annually, periodically as needed, to help pay valid noninsured expenses related to and incurred by needs-based families that use blended diets for G-tubed special needs children.

Timing: Applications accepted, considered, awarded and then publicized, on a rolling basis.

Selection process: Selection of award recipients will be based on the merits of the submitted materials. The awards will only be paid to the proven source of out-of-pocket expenses or reimbursements, related to blended G-tube diets for special needs children. The Fund may request further information or clarification at any point in the process. Ineligible recipients include Fund members/administrators/selectors. New recipients generally have priority over past recipients.

Name of prospective recipient/family,(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

A few sentences (or more) describing your special needs child and their G-tube / blended diet experience(Required)

A few sentences (or more) describing the specific expense/reimbursement being requested, including any coverage or lack thereof for it(Required)

Document upload:(Required)

Do not overburden yourself, but the more documentation you can provide us to prove the need; lack of coverage for it; and actual expense incurred or to be incurred - the more likely we can fully consider your application and approve a valid payment to the correct party. Documents that may help along these lines may include: Health professional's note, receipts, EOBs or similar - and/or anything that verifies the actual party who would receive the funds is the valid recipient.

Max. file size: 50 MB.

Related to above: Exactly where would the money be transmitted/sent? Needs to be an established entity that helps prove the need(Required)

Anything else you think we should know?(Required)

How did you learn about our program?(Required)

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.