Finding Ways to Provide Healthcare at Home

F O U N DAT I O N
Finding Ways to Provide Healthcare at Home
REQUEST FORM
Applicant Name:
Referral By:
Date of Request:
Assistance Requested:
Reason For the Request:
* Homebound: Leaving home takes a considerable and taxing effort.
* Is the patient homebound?
Description of Need: {Identify barriers to care, caregivers in the home or
lack of, community resource availability,
household coping skills, etc…}
Referring Agent Signature:
Phone:
Fax:
Comments:
We strive to respond to complete applications within 72 Hours.
Date received _________________________________
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INCOME AFFIDAVIT
I hereby certify to Ambercare Foundation that my present family income from all sources is
$ ______________{check one: ___weekly, ___bi-weekly, ___semi-monthly, ___ monthly, ___yearly}
with ___________ {provide number} in my household supported by this income. I understand that if
my income changes I will inform Ambercare Foundation immediately. I understand that if any of the
above data is false it may lead to serious consequences.
Yo certifico a Ambercare Foundation que el ingreso presente de toda mi familia es de $_____________
(marque uno: ___ semanal, ___quincenal, ___ dos veces al mes, ___mensual, ___ annual)
con ________ (declare el numero) personas en la vivienda sostenidas con este ingreso.
Entiendo que si el ingreso cambia en el futuro, informaré a Ambercare Foundation inmediatamente.
Entiendo que este es un programa del gobierno Federal y si proveo información falsa, puede llevarme a
consecuencias serias.
I certify that I have told the truth about ALL sources of my family's income. To the best of my
knowledge, I have not given false or withheld information. I understand that if I do,
I may be taken off the program or be made to pay back the benefits I receive.
He dicho la verdad en cuanto TODOS los ingresos de mi familia. Según mi entender, no he
mentido ni retenido información. Comprendo que si miento, puedo ser procesado legalmente,
tenminado del programa o tener que reponer los beneficios que he recibido.
Applicant Signature (Solicitante del Paciente):________________________________
Date (Fecha) :____________
Staff Use:
Weekly
MULTIPLY BY 52
$ _____________
Bi-Weekly
MULTIPLY BY 26
$ _____________
Semi-Monthly
MULTIPLY BY 24
$ _____________
Monthly
MULTIPLY BY 12
$ _____________
Annually
MULTIPLY BY 1
$ _____________
I have seen this document and witness the applicant signature
Employee Signature:________________________________________
Date:________________
EXPENSE AFFIDAVIT
I hereby certify to Ambercare Foundation that my present family expenses from all sources is
$ ______________{check one: ___weekly, ___bi-weekly, ___semi-monthly, ___ monthly, ___yearly}
with ___________ {provide number} in my household supported by these Expenses. I understand that
if my expense change I will inform Ambercare Foundation immediately. I understand that if any of the
above data is false it may lead to serious consequences.
Yo certifico a Ambercare Foundation que el gasto presente de toda mi familia es de $_____________
(marque uno: ___ semanal, ___quincenal, ___ dos veces al mes, ___mensual, ___ annual)
con ________ (declare el numero) personas en la vivienda sostenidas con este gasto.
Entiendo que si el gasto cambia en el futuro, informaré a Ambercare Foundation inmediatamente.
Entiendo que este es un programa del gobierno Federal y si proveo información falsa, puede llevarme a
consecuencias serias.
I certify that I have told the truth about ALL sources of my family's EXPENSES. To the best of my
knowledge, I have not given false or withheld information. I understand that if I do,
I may be taken off the program or be made to pay back the benefits I receive.
He dicho la verdad en cuanto TODOS los gasto de mi familia. Según mi entender, no he
mentido ni retenido información. Comprendo que si miento, puedo ser procesado legalmente,
tenminado del programa o tener que reponer los beneficios que he recibido.
Applicant Signature (Solicitante del Paciente):________________________________
Expense Breakdown:
Date (Fecha) :____________
Utilites
$ _____________
Mortgage/Rent
$ _____________
Insurances
$ _____________
Food
$ _____________
Other
$ _____________
I have seen this document and witness the applicant signature
Employee Signature:________________________________________ Date:________________