Request for Assistance
If you should have any questions during the application process, please email
jasonsevergivingheart@gmail.com. However, if email is not an option, please call Mary at 970-683-0180.

JEGH does not pay the applicant directly. Any bills that are considered for payment are paid directly to the provider.
Your Child’s Needs *
Please explain in detail why your family is in need of financial assistance at this time. JEGH will need a copy of all bills requested for payment at the end of this form.
Your answer
Medical History Information *
Your answer
Child's Full Name *
Your answer
Child's Date of Birth *
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YYYY
Child's Medical Diagnosis *
Your answer
Date of child's last hospital stay *
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DD
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YYYY
How long were you inpatient *
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Physician Name
We may request additional information. In which you will need to obtain from your physician.
Your answer
Did your family lose any income during this hospital stay? *
If yes, estimated total of income lost
Your answer
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