Apply - For the Children

Please identify the medical condition:*

Provide a brief description of medical treatment needed:*

Is this treatment prescribed by a doctor?*

Yes
No

Name of doctor:*

Doctor's address:*

Doctor's phone:*

Reason why referring or need to travel for treatment:*

Please provide the name of the treatment facility:*

Ex. Deaconess Hospital

Treatment facility location:*

Ex. Spokane, WA

Name of doctor at treating facility:*

Please provide the doctor's phone number:*

Dates of medical treatment:*

Total number of days of treatment plus travel days:*

Please check the types of travel expenses you will be requesting for reimbursement:*

Transportation
Lodging
Meals

Check all that apply.

If you selected Transportation, please indicate type(s):*

Car
Train
Airline

If selected Lodging, how many nights stay?*

Is your child covered under private insurance/Healthy MT Kids/Medicaid?*

Yes
No

Select which kind of health insurance you have:*

Private
State
None

Name of your private health insurance:*

Does your private health insurance offer travel reimbursement? If so, how much?*

What kind of state health insurance do you have?*

Medicaid
HMK
Other

Name of Insurance:*

Medicaid/HMK will reimburse for some transportation costs. For more info, call Medicaid Transportation 1-800-292-7114.

Have you been approved for travel reimbursement?*

Yes
No
Not Yet

In addition to our services, state insurance often reimburses travel expenses. Here are links to transportation services:
HMK
MEDICAID

What is amount of reimbursement you have been approved for?*

If denied, briefly state reason:*

How many people living in household 18 and older?*

Please enter a number greater than or equal to 0.

How many people in household under 18?*

Please enter a number greater than or equal to 0.

Annual Household Income:*

Please include SSI, Disability, Workmans Comp, Child Support and any other income sources. You may be requested to provide verification of employment and income for application approval.

Is parent 1 employed?*

Yes
No

Name of employer:*

Is parent 2 employed?

Yes
No

Name of employer:*

Have you or anyone else raised funds for your child’s travel? Ex. Gofundme, community fundraiser event, etc.

Have you received funding from us before? If so, please give total amount.*

Is this a one-time request or will your child need more treatment in the future?

One-Time
On-going Treatment

How many visits are anticipated in the next 3 months?

How did you hear about us?*

Who referenced you to our organization?*

Describe where you heard about us from:*

Financial Assistance

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