The ALTUS Foundation Patient/Client Assistance Referral Form

 
 
 
 
 
Does the prospective referee have medical or applicable insurance?
Total Monthly Household Income (this will be verified): $ /month If the patient is over the income guidelines, but has experienced a sudden loss of income please explain:
What is the purpose for this request?

What is the anticipated impact from this assistance?

Certifications

I certify that, to the best of my knowledge, the information entered into this form is accurate based on verbal responses and other relative information

I have at my disposal pertaining to this patient. *This section should only be signed by a person who is referring a patient to the foundation.

  • *Referring Party' Signature (Mandatory Field)
  • Print Name (Mandatory Field)




I certify that, to the best of my knowledge, the information entered into this form is accurate based on verbal responses and other relative information

I have at my disposal pertaining to this patient. *This section should only be signed by a person who is referring a patient to the foundation.

  • Parent's Signature (or applicable family member) (Mandatory Field)
  • Print Name (Mandatory Field)