OUR MISSION:
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:
*
E-Mail Address:
*
Address:
*
I am the child"s: (select one)
*
Physician
Hospital Social Worker
Medical Specialist
Other
Additional Comments:
By selecting ""I CERTIFY" below, I acknowledge & certify the information I have provided on this Medical Certification Form.
*
I CERTIFY
Please enter your full name below as your electronic signature:
*
Please enter today"s date:
*
-
Month
-
Day
Year
Date
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The Care Fund sincerely appreciates your assistance in providing this information. Please note that 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 insure that you have provided the best contact information for us to reach you.
Thank you!
Care Fund Contact Information:
Address
:
16427 N. Scottsdale Road, Suite 145, Scottsdale, AZ 85254
Phone
: 480.305.8607
Fax
: 480.223.6311
Web
: www.thecarefund.org
Facebook
:
www.facebook.com/CareFundOrg
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