MOLA Disaster Relief Services
MOLA is coordinating with the City of Chicago to provide a list of resources available to evacuees from the natural disaster in Puerto Rico.
Please note that the current expectations are that evacuees will be coming with “no financial or insurance resources” and will not be able to pay for services rendered. Payment and available monies in the future will be completely dependent on a Disaster Declaration and registering evacuees with FEMA for disaster assistance funds.
Name of person completing form
I am interested in opportunities to assist evacuees with health/medical issues in Chicago.
Directly providing services through my hospital / clinic to screen and/or treat evacuees
Personally offering my services at a city-provided location to screen and/or treat evacuees
Providing health education to evacuees
What services would you/your clinic or hospital be able to provide for evacuees?
Adult medical screening / wellness exams
Psychiatric/Psychological evaluations and/or counseling services
Specialist services (please describe in "other")
Interpretation or translation services
How many evacuees per month would you be able to assist with the above services? OR how many hours per month could you offer?
Contact person at clinic/hospital
Contact phone number at clinic/hospital
Name & Location of clinic/hospital
Would you be interested in potentially participating in medical mission trips to areas in need from recent natural disasters (e.g. Puerto Rico)?
Please let us know if you have any additional feedback.
A copy of your responses will be emailed to the address you provided.
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