Lifeline Application

Lifeline Fund Application

This application must be completed by a social worker, nurse coordinator, or other medical professional.

Applications directly from patients cannot be accepted, and will be rejected without consideration.

Part 1: Medical Professional

i-am--from-a(*)

Please select one. This form may only be completed by a medical professional.

from-a-specify

Please provide facility type.

My First Name(*)

Please provide your first and last name

My Last Name*(*)

Please provide patient's last name.

Title*(*)

Please indicate your title.

Institution*(*)

Indicate the hospital/medical facility where you're based.

Address*(*)

Please include a valid address

Institution City(*)

Please insert a valid city

Institution State(*)

Please select your state

Institution Zip(*)

Please provide a valid ZIP code

Phone*(*)

Please provide a 10-digit phone number (123-456-7890)

Email*(*)

Please provide your email address

Please provide a work/institutional email. We cannot accept generic emails (gmail, apple, me, aol., etc.)

Lifeline Fund Application

Part 2: Patient Information

(*)

Please provide patient's first name.

(*)

Please provide patient's last name.

(*)

Please provide date of birth

(*)

Please provide age.

Please Select(*)

Please select one

Address(*)

Please include a valid address

Invalid Input

City(*)

Please insert a valid city

State(*)

Please select your state

ZIP(*)

Please provide a valid ZIP code

Email*(*)

Please provide a valid email

Phone*(*)

Please provide a 10-digit phone number (123-456-7890)

Preferred Language(*)

Please select one

Race/Ethnicity (optional)

Please select one

Is the patient a veteran?(*)

Please select one

Primary Caregiver's Name

Please provide primary caregiver's name

Please indicate caregiver's relationship to patient.

Caregiver's Email

Please provide a valid email

Please provide a 10-digit phone number (123-456-7890)

Lifeline Fund Application

Part 3: Medical Information

(*)

Please provide patient's complete diagnosis

(*)

Please provide transplant date.

Type of Transplant (check all that apply)

(*)

Please provide name of hospital or medical center.

Address*(*)

Please include a valid address

City*(*)

Please insert a valid city

State*(*)

Please select the state

ZIP*(*)

Please provide a valid ZIP code

Physician*(*)

Please provide physician's name

Physician's Email*(*)

Please provide a valid email

(*)

Please provide a 10-digit phone number (123-456-7890)

Nurse Coordinator*(*)

Please provide nurse coordinator's name

Nurse Coordinator's Email*(*)

Please provide a valid email

(*)

Please provide a 10-digit phone number (123-456-7890)

Social Worker*(*)

Please provide social worker's name

Social Worker's Email(*)

Please provide a valid email

(*)

Please provide a 10-digit phone number (123-456-7890)

(*)

Please provide description.

Lifeline Fund Application

Part 4: Financial Information

Note: In the following section, please do not leave any field blank. If value is zero, write $0. If household income is zero, please explain in the next section.

Estimated Monthly Household Expenses

Rent/Mortgage*: $(*)