2018 Request for Assistance Application
READ ALL INSTRUCTIONS AND INFORMATION CAREFULLY! Failure to complete the application fully and correctly may result in denial of support.

You will be able to apply for assistance during the following dates. During the following weeks, applications will be processed.

January 15-22
February 15-22
March 15-22
April 15-22
May 15-22
June 15-22
July 15-22
August 15-22
September 15-22
October 15-22
November 15-22

We primarily use email to communicate. Make sure you type the correct email address, and that you check your email regularly for responses. Be aware that you may need to check your Spam/Junk folder in case your email provider filters send our emails to Spam/Junk.

In order to access The Health Initiative's Community Health Fund and referrals to services, please fill out the application below. The information you share on this application will only be used to determine eligibility for programs and to assist you with locating resources. Information collected on this form is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We will not share any information on this form with any third parties.

The grant funding that makes these services possible requires us to collect certain demographic information. Please answer the questions below to the best of your ability. In addition to grant reporting purpose, the information collected here may help us identify specific programs for which you qualify.

Email address *
Preferred First and Last Names *
Your answer
Legal First and Last Names (if different from Preferred)
Your answer
What pronouns do you use? *
What is your date of birth? *
MM
/
DD
/
YYYY
What is your full address? (Address, City, State, and Zip) *
Your answer
In what Georgia county is your address located? If you are not sure or do not know, please type "Not sure" or "Don't know." *
Your answer
What is your primary telephone number? Please put in format XXX-XXX-XXXX *
Your answer
What is your race and ethnicity? *
What is your gender? *
Required
What is your sexual orientation? *
Required
What is your employment status? *
What is your household size? (How many people are on your tax return?) *
Is anyone in your Household under 18?
What is your estimated YEARLY Household Income (Total income for all those on your taxes)? *
Your answer
If you are a Fulton or Dekalb County resident, do you currently participate in Grady Health System's Financial Assistance Program (have a "Grady Card")?
Do you have health insurance of any kind? (Including employer sponsored insurance, Marketplace, Medicare, Medicaid, and military/VA benefits) *
If yes, what kind of health insurance do you have?
What services or assistance do you need? (Check all that apply, but at least one item) *
Required
If not covered by choices above, please provide us with a brief description of what assistance you need, and we will review for approval on a case-by-case basis.
Your answer
Are you currently receiving any benefits, including but not limited to, SNAP (food stamps), TANF, CAPS, Medicaid, military, disability, whether in the State of Georgia, any other state, or Federal level? If yes, explain in the box below. *
If you answered "Yes" to the question above, what benefits are you currently receiving?
Your answer
Who referred you to this Request for Assistance Application?
Your answer
Read the following statements carefully and check the box next to each to indicate your understanding of and agreement with each policy. 1: *
Required
2: *
Required
3: *
Required
4: *
Required
5: *
Required
6: *
Required
7: *
Required
8: *
Required
9: *
Required
10: *
Required
By submitting this form, I agree and understand that I am submitting a request for assistance from The Health Initiative and agree to the above policies. I understand that I have the responsibility to follow instructions and guidelines in order to receive assistance through the program. I understand that failure to follow procedures as required by The Health Initiative will cause delays or inability to receive assistance. My typed name in the box below will serve as my electronic signature. *
Your answer
A copy of your responses will be emailed to the address you provided.
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