Hope Through Help Foundation
Application for Assistance- By submitting this application, you agree to the following: I understand that my social worker or nurse coordinator will be contacted to verify the diagnosis. Through this process, I will also be actively involved and understand that by not responding/releasing information in an appropriate time frame, assistance can be hindered and/or delayed. I also understand that submission of this application does not guarantee approval for assistance. Assistance is approved based off the availability of funds. Assistance will be rendered in direct payment to the vendor/company as indicated in this application. I am aware that my information is secure and private among the directors of HTHF only. Approval of assistance will be sent via email and will require a signature release.

**we are not currently accepting requests for rent/mortgage assistance** **once funding increases, we will provide an update**

Applications submitted after 12/5/2019 will be reviewed on January 5th 2020.
Email address *
Applicant's First and Last Name: *
Your answer
Mailing Address: *
Your answer
Phone Number: *
Your answer
Type of Assistance Requested: *
Please provide the company name and contact information for remission of payment if approved: *
Your answer
Medical Representative's Contact Info (your social worker or nurse coordinator): *
Your answer
Medical Diagnosis: *
Your answer
Are you the patient or applying on behalf of the patient? *
Are you willing to provide a review of Hope Through Help on social media?
A copy of your responses will be emailed to the address you provided.
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