Medical Aid Questionnaire

As a matter of policy, we do not ever give cash directly to the patient / individual or family who applied for assistance

via Hugs For Mito, Inc.

We assist the individual or family who has requested our assistance by remitting payment directly to the vendor or creditor whom we receive durable medical equipment and supplies.

By operating in this manner, our donors can always be certain that the contributions they've made available to our qualified patients and families serve only the purpose for which they were intended.

First Name

Email Address

Last Name

Patient / Individual's Date of Birth

Address

City

Zip Code/Postal Code

Country

State/Province

Phone Number

Relationship to patient / recipient of durable medical equipment and supplies?

Why are you requesting assistance?

Medical Equipment

Supplies

Assistive Mobility Device

Has the patient / individual been hospitalized in the last 12 months?

Yes

If you answered yes, please elaborate

Has the patient / individual received a formal diagnosis?

Yes

Patient / Individual's Disease. If not formally diagnosed, what is the suspected disease?

Doctor's Evaluation Required

Please upload a doctor's evaluation of the patient's / individual's disease or suspected disease.

Upload supported file (Max 15MB)

Cost Of Care

Itemized expenses of the patient's / individual's care.

Upload supported file (Max 15MB)

Cost Of Care

Itemized expenses of the patient's / individual's care.

Upload supported file (Max 15MB)

Cost Of Care

Itemized expenses of the patient's / individual's care.

Upload supported file (Max 15MB)

Does the patient / individual have health insurance?

Yes

How many people reside in the patient's / individual's household. Please include the patient / individual in your count.

Household Income

Comments:

Initials

Today's Date

Your Signature

I declare that the info I’ve provided is accurate & complete.

Thank you for submitting!

508.813.6794

Hugs For Mito does not provide medical advice, diagnosis or treatment.

Hugs For Mito is a non-profit organization (Tax ID number 81-4919859), and qualifies as a tax-exempt organization under section 501(c)(3) of the IRS. Hugs For Mito and has been designated as a “public charity” under section 170.