Care Fund Medical Certification

Our mission is to financially and resourcefully support Arizona families who endure financial hardship while experiencing extended illness or injury of their children. The Care Fund provides mortgage or rent support during a child's extended health crisis.

Medical Certification

This form is to be completed by the child's medical care provider or the hospital social worker, in conjunction with the Housing Expense Assistance Application.

Child's Name (affected by illness or injury): *

Child's Birth Date:

Child's current condition: *

Stable Critical Declining

The undersigned hereby certifies (please check ALL to confirm): *

That I am duly licensed by the State of Arizona to practice medicine, That I am a physician involved in the treatment of the child/patient named above, That I understand that the foregoing certification is required by the Care Fund in order for the child/child"s family to be considered eligible for housing expense assistance.

The child's diagnosis is as follows (please provide as much detail as possible): *

Potential outlook for the next 6-9 months for the patient. (Inpatient or outpatient treatments, rehab, hospitalization, surgery, etc). Please provide as much detail as possible.

Name & professional designation of individual completing this certification: *

Hospital Affiliation: *

Phone Number: *

Email Address: *

Address: *

I am the child's: (select one) *

Additional Comments:

By selecting "I CERTIFY" below, I acknowledge & certify the information I have provided on this Medical Certification Form. *

Please enter your full name below as your electronic signature: *

Please enter today's date: *

Date

The Care Fund sincerely appreciates your assistance in providing this information. A member of the Care Fund Team will contact you after receipt of your certification, to verify the information either verbally or in writing. Please ensure that you have provided the best contact information for us to reach you.

Thank you!
Care Fund
www.thecarefund.org
480.305.8607 phone
480.223.6311 fax

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